Fecal Incontinence Treatment
Depending on the severity of fecal incontinence, therapy to manage the incontinence can range from conservative measures (such as diet, fiber supplementation, anti-motility drugs and biofeedback) to anal sphincter reconstruction.
Solesta is a minimally invasive, biocompatible tissue bulking agent, indicated for the treatment of fecal incontinence in patients 18 years and older who have failed conservative therapy. It is administered as four injections in an office-based procedure via anoscopy.
The clinical studies supporting Solesta demonstrated both a dramatic reduction in the number of fecal incontinence episodes as well as durability up to 24 months. In those studies, patients had significantly better control of their bowel movements, fewer leaks, and more days without accidents. Additional studies are ongoing and our office will be participating as an open label, post-FDA approval site to further evaluate Solesta’s efficacy.
The most common risks of treatment associated with Solesta are mild or moderate pain or discomfort in the rectum, and minor to moderate bleeding or spotting from the rectum following treatment. A few patients experienced a fever, abdominal pain, or diarrhea or constipation after treatment. Most of these side effects were mild or moderate and resolved within two weeks.
InterStim, or sacral nerve stimulation is stimulation of the third sacral nerve root to improve bowel control. The same technique has been approved by the FDA for use by our urology colleagues for management of urinary incontinence since 1997. Sacral nerve stimulation has been available in Europe and Canada for the treatment of fecal incontinence for years, but only in the second half of 2011 gained FDA approval.
In a recent study of 132 patients with fecal incontinence greater than or equal to twice weekly, InterStim was able to reduce the number of episodes by at least 50% in 83%. 41% of patients reported complete continence. Test stimulation was performed over 2 weeks using a chronic implant lead, to determine probable success of sacral nerve stimulation. Successful test stimulation, defined as a > 50% reduction in their symptoms, was required before permanent implantation with InterStim. If the test stimulation was not successful, the test lead was simply removed. The most common adverse events included pain at the implant site, numbness and tingling, and implant site infection.
An overlapping sphincteroplasty is an operation performed to restore normal anal sphincter anatomy following an injury, or disruption, to the anal sphincter muscle that has lead to the development of fecal incontinence. Oftentimes, this injury is the result of trauma from a vaginal delivery. When the sphincter is disrupted, the muscle may not be able to squeeze and tighten effectively to prevent passage of stool, leading to fecal incontinence. The surgeon will reconnect the free ends of damaged muscle to reestablish the sphincter as a ring, leading to improved function. Sphincteroplasty has been used for decades in the treatment of fecal incontinence and is a very safe operation.
Preparation before surgery:
- If you smoke, quitting is an important way to optimize healing.
- A bowel preparation, similar to what is done prior to a colonoscopy will be need to be completed the day before surgery.
- The operation is performed on an inpatient basis, with an expected hospital stay of about 3 days.
- You can expect to have a wound to care for after your operation. Your doctor will provide you with specific instructions.
- It is normal to have pain after your surgery. You may experience more pain with bowel movements. Your doctor will prescribe pain medication for you to take after surgery.
- It is important to avoid constipation initially following an overlapping sphincteroplasty. Eating a soft diet and taking a gentle laxative, such as Miralax can help avoid this.
Overlapping sphincteroplasty has been shown to be initially successful in up to 75% of patients with severe fecal incontinence and is necessary in cases where normal anatomy has been severely disturbed. However, there have also been discouraging reports about deterioration in function over time. In two studies, about half of the patients who underwent this treatment said they were experiencing some urinary or fecal incontinence, had required further surgery, or had developed other bowel problems, when contacted four to 12 years later. Fortunately, we now have additional therapeutic interventions available to improve function if this occurs.