Sphincter Repair and Sacral Neuromodulation

Introduction

Fecal incontinence is a devastating problem. The incidence has been cited between 1% and 18% based on several studies. However, even at this rate, this symptom seems to be under-reported, with true incontinence (that excludes incontinence of flatus) thought to be around 7% to 8%.

The initial treatment of fecal incontinence is usually by conservative means involving diet and bowel management. This is done by eliminating foods that may contribute to diarrhea and exploring food allergies. Inclusion of fiber may also help decrease symptoms in some patients. Kegel exercises, by patient alone or using a physical therapist to direct sphincter contractions, are a mainstay of initial approaches. Antidiarrheals and probiotics may be other medications that are often necessary to control symptoms. Finally, rectal irrigation is an option for patients who have fairly normal bowel movements but continue to leak after a bowel movement. However, despite this multimodality approach, many patients still experience symptoms affecting quality of life.

When conservative management fails, future options are based on an assessment of patient symptoms and expectations. Nonoperative management involves the use of anal plugs such as the Renew insert or the Procon 2 device. Other nonoperative managements include the Eclipse device and the Secca procedure. Surgical options also still exist. Sphincteroplasty is an option for patients who have a sphincter defect of less than 180 degrees, and sacral neuromodulation with an implantable device has more recently had significant success at improving incontinence. In this chapter, we explore the latter two procedures in the treatment of fecal incontinence.