Faecal Incontinence – Review of the Disease State, Therapeutic Alternatives and Algorithmic Approach to Treatment

Touchgastroenterology.com; November, 2011

SUMMARY: Chronic intractable FI is a multifactorial, multidimensional and significantly prevalent disorder that carries significant psychosocial consequences and stigmata that deeply affect the lives and wellbeing of its victims. In the absence of a readily correctable cause of the underlying bowel control disorder, the incontinence is most often associated with anal sphincter trauma caused by obstetric or surgical injury. Chronic straining, degenerative changes and ageing are also considered potential significant components. There are multifaceted contributions of obstetric and non-obstetric risk factors, often implicating pelvic floor injury. Initial clinical assessment and diagnostic testing are directed towards excluding and, if found, treating correctable aetiologies. If no fixable anatomical or physiological disturbance can be found, it is important to design a treatment approach tailored to the cause of the patient’s symptoms, beginning first with the most benign therapies and advancing in a stepwise manner to more advanced options. Some components of the disorder may be amenable to diet, medication or scheduled bowel evacuation. Although it is not yet completely clear which, some aspects may respond favourably to biofeedback. surgical sphincteroplasty has its place in the carefully selected patient with specific recent sphincter injuries amenable to immediate repair. Newer therapies should be employed in a logical order so as not to create a contraindication to other treatment options, and with an eye towards limiting the complications that are prevalent in the more invasive procedures. Based upon the underlying sphincter defect, some procedures may be contraindicated or limited in effectiveness. When initial medical therapy or biofeedback fails, intermediate level procedures such as transanal RF ablation (secca) should be considered as initial stepped therapy, because of the reported short and long-term success rates, low cost and the fact that there is no contraindication to undergo any of the other, more advanced procedures in the event of failure. The next level of therapy may then fall to injection therapy. If injection therapy is contraindicated, due to the level of the sphincter defect, or unsuccessful, then SNS would be the next most appropriate intervention based upon its rate of success and low complication status. Ultimately, in the event of failure of the prior techniques, artificial sphincter implantation and dynamic graciloplasty, which are associated with much higher morbidity, may be employed, especially as both procedures are associated with reasonable improvement in FI.