Surgical Management of Fecal Incontinence: A Historical Perspective

Abstract

Fecal incontinence (FI) is a diagnosis that is prevalent but often overlooked. With the devastating effect that FI has on patients, it is imperative that providers have the tools and knowledge to elicit information on FI symptoms from patients and provide management options for this condition. The historical management for patients with FI had not had significantly positive results until the emergence of sacral neuromodulation. This article discusses the historical background of the assessment and management of FI and the surgeries that have transformed treatment options for patients who suffer with this condition. (J GYNECOL SURG 39:142)

Introduction

Fecal incontinence (FI) is a hidden diagnosis, often not brought up by the patient or the physician. However, its prevalence is significant, affecting 7%–15% of the community-dwelling population.¹ In women, specifically, it has been shown that the median prevalence of FI is 8.9%, ranging from 2.0% to 20.7%.² It is difficult to ascertain the true prevalence of FI, as there is an aspect of embarrassment and shame that accompanies the diagnosis. It is now known that its prevalence is much higher than previously thought, given current availability of questionnaires and efforts to normalize these symptoms during discussions in clinical settings. The cost to patients also is significant, with one study estimating annual costs for a women with FI to average about $4,110.³ Therefore, it is imperative to understand the diagnosis and management of FI to improve patient quality of life and help ease the financial burden of this condition.

In 1543, the colon, rectum, and anus were described and illustrated by Andreas Vesalius, a well-known physician, anatomist, and the author of De Humani Corpis Fabrica (cited by Rispoli and Rispoli).⁴ It wasn't until the fifteenth century that the anal sphincter was illustrated by Leonardo da Vinci. It was illustrated as a flower with five petals.⁴ It is now known that the anal sphincter complex has an internal and an external anal sphincter. The puborectalis muscle, a component of the levator ani muscles as well as the anal sphincter complex, encircles the anorectal junction. The rectoanal inhibitory reflex allows contents from the rectum to be sampled by the anus at various times during each hour. This allows the internal anal sphincter to relax and the external anal sphincter to contract until the appropriate time arises to expulse the stool or flatus.⁵ Without this reflex, there would be minimal control for bowel movements or passing flatus.

The most-common causes of FI are anatomical dysfunction of the anal sphincter complex, abnormal stool consistency, and neurologic issues. For women, the most-common cause in disruption of the anal sphincter complex is vaginal delivery. Anal sphincter tears during delivery significantly increase the risk of FI in the future. Of women with anal sphincter tears, 17% have FI 6 months postpartum, while 8% of the same cohort of women without anal sphincter tears also have FI 6 months postpartum.⁶ For other women, FI due to sphincter injuries may not manifest until later in life due to muscle atrophy and the inability of accessory muscles, such as the puborectalis, to compensate for anal sphincter dysfunction.

However, it is speculated that many women are not diagnosed with obstetric anal sphincter injuries (OASI) at the time of delivery and have occult injuries leading to FI of unclear etiology later in life. One prospective study found that, by using ultrasound (US) 6 weeks postpartum, 35% of primiparous women had sphincter damage, while 44% of multiparous had sphincter damage.⁷ The true incidence of OASI is much higher than the reported incidence of OASI, which varies from 0.1% to 10.9% in different studies.⁸ Additionally, changes in stool consistency lead to FI as flatus and loose stool are the most-difficult to control.

Other causes of disruption of the anal sphincter complex include history of surgery, such as fistula repair, hemorrhoidectomy, sphincterotomy, radiation, trauma, or congenital anomalies such as imperforate anus.⁹ Pregnancy alone also is a risk factor for anal incontinence, with a cumulative incidence rate of 10.3% in primiparous women who were previously continent and healthy.¹⁰ Chronic illness, chronic diarrhea, smoking, and obesity are also known risk factors for FI.⁹

Evaluation

The National Institute of Diabetes and Digestive and Kidney Diseases defines fecal incontinence as “unintential loss of solid or liquid stool.”¹ Anal incontinence is a term describing the accidental passage of flatus in addition to fecal incontinence. The most essential component to the diagnosis of FI is the history that is elicited from the patient. As discussed, it may be difficult for patients to offer information about their symptoms, so it becomes the task of the provider to inquire about them. It is important to gain an understanding of the symptoms by asking about stool consistency, frequency of bowel movements, and frequency of FI episodes.

Circumstances of bowel leakage must be elicited as well. For women who have had vaginal deliveries, a detailed obstetric history is vital. The provider should inquire about vacuum or forceps use during delivery and/or history of third- or fourth-degree lacerations. During this history-taking, the provider must also screen for “red flag” symptoms and symptoms of other disease processes. These include symptoms such as sudden or chronic changes in caliber or consistency of stool not related to diet, tarry or dark-colored stools, or blood in stools. If these symptoms are encountered, it is important to make sure the patient is referred to a gastroenterologist and/or is up to date on her colorectal cancer screening.

There are different scoring systems available to assess the symptoms of FI. In 1993, Jorge and Wexner proposed an incontinence grading scale¹¹ that is now also known as the Cleveland Clinic score. Other scoring systems include the Parks scale (1983), the Pesactori score (1992), and the St. Mark's (Vaizey) score (1999).¹² The Bristol stool chart, created in 1997 in Bristol, England, initially to monitor change in intestinal function,¹³ is a tool that can be used to assess consistency of stools in patients who suffer from FI.

Perineal and rectal examinations are key components in the physical examination of women with anal incontinence. First, overall appearance of the anal opening should be noted. Fecal soiling may be present and signs of skin irritation or breakdown due to use of incontinence garments or exposure to fecal material may be present. The “dovetail” sign refers to the loss of folds around the anus anteriorly and is a possible sign that the external anal sphincter is disrupted. The presence of external hemorrhoids and rectal prolapse should be evaluated as well. A digital rectal examination should be performed, with the patient at rest and while squeezing. Puborectalis muscle lift can also be assessed during the digital rectal examination. Palpation for rectal masses or a rectocele is included in the rectal exam.

During the pelvic examination, the provider should also assess for the presence of a rectovaginal fistula. Assessment for fistulae may include a vaginal speculum examination to assess for fecal material in the vagina or a rectovaginal examination to evaluate for defects in the rectovaginal septum. If the defect is small, lacrimal duct probes or rectal examination with a dyed lubricant jelly can aid in localizing a fistulous tract.

Endoanal US is known as the gold standard for radiographically viewing the anal sphincter complex, with US sensitivity and specificity being 100% for external anal sphincter defects.¹⁴ This procedure was first described in 1989 by Law and Bartram using a radial 7-MHz probe and was noted to be rapid and simple with high-resolution images.¹⁵ Since this time, endoanal US has evolved, and it is possible to construct 3-dimensional (3-D) and 4-D images of the sphincter complex. US use is helpful, especially when there is a known injury or defect in the anal sphincter complex and if surgical management is being considered. Magnetic resonance imaging (MRI) visualizes the external anal sphincter well and can be used for assessing its integrity. However, measurements are not standardized.¹⁶ MRI is a costly modality, and this should be considered when selecting an imaging study. There are no current guidelines for when imaging is indicated.

Nonsurgical Treatments

There is no consensus on when FI was first mentioned in texts. Colonic irrigation is thought to be the first treatment for FI. It was described by Egyptian, Babylonian, Assyrian, and Hindu texts as early as the fifth century bc.⁴ Current nonsurgical treatments for patients with FI include changing dietary habits, fiber supplementation, antidiarrheal medications, and pelvic floor physical therapy.¹⁷ It is important to make sure a patient's stool is formed, as looser stools may lead to seepage and are not easily controlled. If the patient has a chronic condition causing loose stools, such as inflammatory bowel disease, it is important to treat the patient's disease process accordingly. In many cases, this requires co-management with a gastroenterologist.

Vaginal and anal inserts are also options before surgical treatment is pursued. The Eclipse^tm System, which recently underwent clinical trials in 2015, is a device that is placed intravaginally and inflates to compress the rectum.¹⁸ Inserts have low morbidity and risk, and can be used with proper patient counseling. The American College of Obstetricians and Gynecologists (ACOG) recommends against surgical treatments for initial management of FI, except for fistulae and rectal prolapses.¹⁹

Surgical Treatments

Historical treatments of fecal incontinence

In the early-to–mid-twentieth century, a series of surgeries were performed for weakened sphincters.²⁰ R.R. Wreden, MD,²¹ and Harvey Stone, MD,²² were the first to describe sphincter reconstruction using fascia in 1929 and 1932, respectively, which was later re-described by Stone and McLanahan, with updated techniques in 1941.²³ Using the gluteus maximus or gracilis muscles to create a neosphincter (also known as transposition) was described as well. The gluteus maximus was the first to be described in 1902, followed by the gracilis muscle for transposition.²⁴

The gracilis flap was a more-popular surgical technique at the time, as it is a long and flat muscle and only requires unilateral mobilization when wrapping the anus.²⁴ Pickrell et al. first described gracilis muscle flaps in 1952, which he created for children with neurologic dysfunction.²⁵ It was then discovered that these muscles could tire easily, and complete continence was rarely attainable. In 1988, an implanted neuromuscular stimulator was used in conjunction with the previously implanted gracilis flap (a procedure later known as dynamic graciloplasty).²⁶ This provided a resting tone for the neosphincter. This technique was never approved by the U.S. Food and Drug Administration (FDA).

Artificial anal sphincter

Artificial anal sphincters have been studied, but, currently, they are not first-line treatments. Studies are still ongoing. There are high rates of complications with these devices. Therefore, the American Society of Colon and Rectal Surgeons (ASCRS) reserves artificial bowel sphincters for patients with severe FI for which other treatments have failed.²⁷

Anal bulking

Anal bulking was first described by Ahmed Shafik, MD, in 1993 using polytetrafluoroethylene injections. He injected 11 patients, and had complete cure rates of 45.4% after the first injection and 63.6% after the second injection. The remaining 36.4% had some improvement.²⁸ Many materials have been used for bulking. In 2011, dextranomer microspheres in nonanimal-stabilized hyaluronic acid was approved by the FDA and is the only bulking material that is approved at this time. A Cochrane Review in 2013 found that this substance improved incontinence in the short-term.²⁹ Trials are limited, and long-term effects of anal bulking are unknown.

Anal sphincteroplasty

Anal sphincteroplasty was the surgery of choice for many years in patients with anal sphincter defects and injuries. However, with the emergence of sacral neuromodulation, the frequency of this procedure has decreased.¹⁷ Warren was the first to describe sphincter repair in 1882.³⁰ He described the operation as “shutting out the rectum entirely by a flap operation,” which “consists of vaginal and mucous membrane, and also of a certain amount of cicatricial tissue which is to be found at the margin of the rent.”

There are two techniques for sphincter repairs. The first is End-to-end repair of the external anal sphincter and the second is overlapping repair. End-to-end repair was first described in 1971 by Parks and McPartlin.³¹ The overlapping technique was described soon after in 1977.³² There seems to be no differences in long-term outcomes between methods.³³ One Cochrane Review concluded that there was no difference in dyspareunia, flatus incontinence, and perineal pain when comparing the 2 techniques, but there were lower fecal urgency and anal incontinence scores in patients treated with the overlapping technique.³⁴ At 36 months, there was no difference in FI and flatus incontinence between the two techniques.³⁴ ACOG recommends that either repair is acceptable with full thickness external anal sphincter lacerations.³⁵ Ultimately, surgeons' comfort levels will play a role in the kinds of sphincteroplasty performed and the success rates of their work.

Studies have shown that patients may have poor long-term outcomes with sphincteroplasty.³³ With the emergence of sacral-nerve stimulation for treating FI, the role of anal sphincteroplasty has decreased. Both the ACOG and the ASCRS agree that sphincteroplasty is an option for patients for whom conservative treatment fails.^19,27 However, repeat sphincteroplasty after a failed surgery should be avoided.²⁷ Bharucha et al. advise that sphincteroplasty should be considered for postpartum women closer to delivery, also known as early sphincteroplasty.³⁶ Those that present farther from delivery with symptoms should first be offered conservative therapies, bulking, and/or sacral-nerve stimulation.³⁶ If late sphincteroplasty (also termed secondary sphincter repair) is performed, there is very little data to support outcomes. However, in one study with a 10-year follow up after sphincteroplasty, 40% of patients were continent.³⁷ This suggests that long-term outcomes decline with time.

In 1975, Parks (cited by Rispoli and Rispoli)⁴ described “postanal repair,” which was meant to lengthen the vaginal canal, restore anorectal angle, and produce a flap valve mechanism.⁴ The Parks postanal repair, (also known as plication of the external anal sphincter), is not recommended per the ASCRS, as its effectiveness is not established.²⁷

Sacral-nerve stimulation

Drs. Rick A. Schmidt and Dr. Emil A. Tanagho, MD, are credited with the first clinical work on sacral neuromodulation. The trials performed were mostly for urinary incontinence symptoms. Sacral-nerve stimulation was first approved for treating urinary incontinence by the FDA in 1998 using the InterStim system. The first study using sacral-nerve modulation was in 1995, which followed 3 patients after applying electrostimulation to the sacral nerves. Of these 3 patients, 2 were completely continent 6 months later and the third patient had improved.³⁸ Trials did show that, not only was sacral-nerve stimulation effective for treating urinary incontinence, but it was also a safe and successful treatment for patients suffering with FI.³⁹ Sacral neuromodulation was FDA-approved for treatment of FI in 2011.

Sacral-nerve stimulation has shown to be effective long-term, with 89% of patients having >50% reduction of symptoms and 36% having complete continence.⁴⁰ The ASCRS “Clinical Practice Guideline for the Treatment of Fecal Incontinence” states that “sacral neuromodulation may be considered as a first-line surgical option for incontinent patients with and without sphincter defects.”²⁷ The society grades this recommendation as “strong.” This intervention has gained popularity as a first-line surgical treatment, as it is effective, minimally invasive, and has minimal risk.

Colonic diversion

Colonic diversion is a reliable option for patients with severe FI, and it is a last resort option.¹⁷ Stoma creation is known as the first surgery for the treatment of FI. It was performed by Pillore in 1776 (cited by Rispoli and Rispoli).⁴ In a study of patients who had colonic diversions due to FI, 83% of patients felt like the stoma restricted their life “a little” or “not at all,” and 84% said they would “probably” or “definitely” chose this procedure again.⁴¹ Although it is a successful treatment, it is usually reserved for patients for whom all other management options fail.

Conclusions

With the normalization of discussing FI in the clinical setting, FI diagnosis and surgical management have been able to grow immensely. The emergence of sacral neuromodulation has benefitted patients. Although new devices and techniques have emerged and have changed the lives of patients drastically, some providers feel that the strides have been slow and that options are limited. With the devastating impact that this diagnosis has on patients, continued research on prevention and management are still needed to continue to provide excellent, evidence-based care.

Footnotes

Authors' Contributions

Both authors conceptualized, wrote, and edited this article.

Author Disclosure Statement

No financial conflicts of interest exist.

Funding Information

There was no funding involved with this article.

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