Fecal incontinence - Challenges and solutions

Table 1 Causes of fecal incontinence

Category	Details
Acquired structural abnormalities	Obstetric injury (vaginal delivery)
	Anorectal surgery (hemorrhoid, fistula, fissure, etc.)
	Rectal intussusception/prolapse
	Sphincter-sparing bowel resection
	Trauma (e.g., pelvic fracture, Anal impalement)
Functional disorders	Chronic diarrhea
	Irritable bowel disease
	Inflammatory bowel disease
	Radiation proctitis
	Malabsorption
	Hypersecretory tumors
	Fecal impaction (paradoxical diarrhea)
	Physical disabilities
	Psychiatric disorder
Neurological disorders	Pudendal neuropathy
	(radiation, diabetes, chemotherapy)
	Spinal surgery
	Multiple sclerosis
	Dementia
	CNS disorder: stroke, trauma, tumor, infection
	Spina bifida
Congenital disorders	Imperforate anus
	Cloacal defect
	Spina bifida (myelomeningocele, meningocele)

Table 2 Cleveland Clinic Fecal Incontinence Score[12]

Parameter	Frequency
	Never	Rarely	Sometimes	Usually	Always
		(< 1/mo)	(< 1/wk but ≥ 1/mo)	(< 1/d but ≥ 1/wk)	(≥ 1/d)
Incontinence to solid stool	0	1	2	3	4
Incontinence to liquid/loose stool	0	1	2	3	4
Incontinence to gas	0	1	2	3	4
Wears pad	0	1	2	3	4
Lifestyle alteration	0	1	2	3	4

Sum of the five parameters: perfect control = 0; complete incontinence = 20.

Table 3 Structured workup of patients with fecal incontinence

Assessment tool	Details
History	Onset
	Quantitation: staining < soilage < seepage < accidents
	Qualitative assessment: passive incontinence vs urge incontinence
	Obstetrical history: pregnancies, vaginal deliveries
	Previous surgeries: anorectal surgeries, hysterectomy, bladder surgeries, (colo)rectal surgeries, spinal surgeries
	Underlying diseases (diabetes, stroke, etc.)
	Bowel function and stool quality
	Incomplete evacuation
	Stool/gas passage through vagina
	Medications
Scoring instruments	CCF incontinence score (“Wexner score”)
	Fecal Incontinence Quality of Life score
	Fecal Incontinence Severity Index
	St. Marks Incontinence Score
	EORTEC SF-36
	Revised Fecal Incontinence Scale
	Other scoring instruments
Physical exam	Inspection: patulous anus, folds, perineal body, keyhole, skin irritation, perineal descent, prolapse, cloaca, rectovaginal fistula (stool in vagina)?
	Digital exam: sphincter integrity, tone (rest/squeeze), compensatory contraction/discoordination, rectocele, mass?
	Sensation/anal reflex
	Instrumentation/visualization: rule out other pathologies (e.g., rectal tumor, proctitis)
Anophysiology testing	Anal ultrasound
	Anophysiology testing:
	Manometry
	Anorectal sensation and volume tolerance
	Compliance measurement
	Nerve studies: PNTML, occasionally EMG
	Placement of SNS trial electrode (phase I)
Additional evaluations in select cases	Imaging: dynamic pelvic MRI
	Defecating proctogram
	Evaluation by other specialties (Urogynecology, Urology, Gastroenterology, etc.)

Table 4 Surgical strategies

Goal	Options
Correction of morphological deformities	Prolapse
	Cloaca
	Keyhole deformity
	Perirectal fistula
	Rectovaginal fistula
	Tumor
Sphincter repair	Overlapping sphincteroplasty
Enhancement of impaired sphincter function	Sacral nerve stimulation
	Radiofrequency energy administration (SECCA™)
	Injection of bulking agents (NASHA/DX, beads etc.)
Sphincter replacement/support	Artificial bowel sphincter
	Implantation of magnetic anal sphincter (Fenix™)
	Graciloplasty
	Implantation of Thiersch
	Implantation of pelvic sling system
Diversion	Colostomy
Reduction of fecal load	Malone antegrade continence enema

Table 5 Types of injectable/implantable materials

Category	Details
Conventional	Carbon
	Teflon or silicon biomaterial beads
	Collagen
	Autologous fat
Newer	Non-animal stabilized hyaluronic acid/dextranomer
Pilot	Self-expandable hyexpan (polyacrylonitrile) prosthesis
Future	Stem cells

Table 6 Overview of various surgical options with respective outcomes (as detailed in the text)

Interventions category	Specific technique	Efficacy rate (complete/> 50% improvement)	Complication rates	Grade
Correction of morphological abnormalities	Depending on underlying condition:	N/A	N/A	N/A
	Prolapse, cloaca, keyhole deformity, perirectal fistula, rectovaginal fistula, tumor
Sphincter repair	Overlapping sphincteroplasty	75%-85% (short term)	N/A
		0-50% (after 5-10 yr)
Enhancement of sphincter function	Sacral nerve stimulation	0%-56%/51-100%	lead displacement (15%), diarrhea (6%), pain (6-28%), bleeding 11%, infection (3%)	1B
	Tibial nerve simulation	0%-12% (-40%)/0%-67%	59% (infection, mild gastrodynia, temporary leg numbness)	2C
	Radiofrequency energy administration	0%/12%-38% (-84%)	0%-52% (pain, bleeding, infection)	2B
	Injection of:	0%/33%-90%	10%-12% (pain, bleeding, infection)	2A
	conventional bulking agents	6%/56%-61%
	NASHA/DX
Sphincter replacement	Artificial bowel sphincter	61%-90%/31%-100%	5%-10% infection rates, 30%-52% long-term failure 9	1B
	Implantation of magnetic ring (Fenix™)	NA/54%	0%-7% obstruction, infection, erosion	1C
	Graciloplasty (dynamic/non-dynamic)	NA/72%	> 40% including urinary tract infection/retention, infections 76	2C
	Implantation of Thiersch	N/A	N/A	N/A
	Pelvic floor repairs/sling	19%/69.1%	17%-30% (pain, infection)	2C
Fecal diversion	Ileostomy, loop colostomy, end colostomy	near 100% FI improvement	5%-10% stoma outlet obstruction, stricture, prolapse, hernia	1C
Fecal load reduction	Malone antegrade continence enema	(0%)/33%-100% FI continence	8%-50% stoma stenosis, leakage	2C