Table of Contents  

Matzel, Cui, and Bittorf: Faecal incontinence

Introduction

Faecal continence is the result of the integrated function of various organs and their peripheral and central nerve supply. Trauma to any of these components can cause a functional deficit, i.e. the inability to prevent involuntary loss of bowel content. The psychological and social consequences of faecal incontinence can be devastating. Even though the condition is widespread (affecting approximately 2% of the general population),1 it remains under-reported. The problem increases with age, with up to 11% of men and 26% of women reporting incontinence after age 50 years.2 In nursing homes, up to 40% are affected, most often in combination with urinary incontinence.3

With better diagnostic methods, the understanding of the physiology and pathophysiology of the various components of the anorectal continence ‘organ’ has improved in recent years. Faecal continence is maintained by the synergistic functioning of the reservoir system of the rectum, the outlet resistance of the sphincter complex and the sensory lining of the anal canal. This coordination is attained by a convergence of somatomotor, somatosensory and autonomic innervation. A functional deficit of a single anatomical component of this complex system may not, in itself, result in incontinence because other components can be compensatory. Thus, insufficiency of the anal sphincter need not necessarily result in faecal incontinence as multiple factors are often in play.

Although rectal reservoir function can be addressed with replacement after resection or with refixation in cases of rectal prolapse, surgeons will most often need to address sphincteric function (by augmentation or substitution) because trauma to the sphincter complex is the most common cause of uncontrollable loss of bowel content.

Therapy dedicated to sphincter insufficiency is recommended if the patient is symptomatic, the functional insufficiency of the sphincter and its relevance for symptoms have been proven, and once other potential causes of faecal incontinence have been excluded. Furthermore, surgical treatment of anal sphincter insufficiency is recommended if conservative treatment does not result in adequate symptom relief and no specific or general contraindications exist.

The treatment of faecal incontinence is mostly pragmatic. First-line therapy is conservative, consisting of a spectrum of options4 that aim to affect the involved organ functions, e.g. diet, medical modification of stool passage, regular emptying with the aid of irrigation. However, this work focuses on surgical treatments for anal sphincter insufficiency and their role in the evidence-based algorithm in current use.5 It will outline the therapeutic potential of recent developments, although stoma creation as an ultimate choice lies outside the purview of this discussion. Diagnostic procedures will be addressed only if they impact surgical decision-making.

Diagnostic and treatment considerations

The diagnosis of faecal incontinence is based on a standard anorectal examination (to exclude pathological conditions that may result in secondary incontinence) and a focused history. The latter includes stool frequency, urge symptoms, incontinence for gas, liquid or solid stool, difficulties in passing stool, necessity of digital help when emptying and day and time dependence of symptoms. The use of bowel habit diaries, standardized questionnaires as well as general and disease-specific quality scores helps to document the symptoms in detail and to quantify the extent and severity of the disorder. Decision-making is based not solely on the extent of symptoms but also on their impact on quality of life. The same instruments are used to monitor the clinical efficacy of interventions.

Most cases of incontinence can be treated with relatively simple pragmatic measures, and a commonly accepted principle is to proceed with the simplest, least invasive, treatment first. Conservative options such as diet, medication, and retrograde irrigation can, without further diagnostic steps, be initiated to improve stool consistency and delayed colonic transit and to establish a normal periodicity to bowel emptying. If these fail or do not produce adequate results, further diagnostic procedures are indicated to differentiate muscular from neurogenic and combined lesions.

A range of diagnostic instruments is available to identify morphological and functional deficits of the various structures and functions contributing to the maintenance of continence. This is important to establish a meaningful therapeutic concept, as the cause of faecal incontinence is multifactorial.

Comparable morphological and functional lesions may result in clinical pictures of varying severity. Anatomy and its potential defects can best be explored with endoanal ultrasonography and magnetic resonance imaging. Endoanal ultrasonography is easy to perform and is an essential part of the diagnostic workup.

The muscular function of the smooth muscle internal anal sphincter and the striated muscle external anal sphincter, the perception of rectal filling and distension, the compliance of the rectal reservoir and the reflexive interaction of the rectum and anal sphincter can be tested and quantified by anorectal manometry. Electromyography (EMG) recordings of the external anal sphincter and the pelvic floor permit differentiation of muscular from neurogenic defects and estimation of the extent of reinnervation. Pudendal nerve terminal motor latency (PNTML) measures the conduction velocity of the peripheral pudendal nerve and helps to identify relevant lesions. EMG and PNTML have limited impact on decision-making.

Surgical treatment of anal sphincter insufficiency

Based on the diagnostic findings, two concepts for treating anal sphincter insufficiency can be distinguished. The first is functional rehabilitation, which is recommended if no morphological defects are identified and aims to recruit residual function of the anorectal continence organ. The second is morphological reconstruction, which is recommended if the identified morphological defects have a functional relevance.

Functional rehabilitation

As stated above, conservative therapies should be attempted first, and only if they fail to provide adequate symptom relief should surgical intervention be considered.

Biofeedback can be the first option for therapy. Visual or acoustic signals are used to teach the patient awareness and use of specific physiological functions (both motor and sensory) and thus recruit residual function.6,7 The therapy is based on the principle of operant conditioning and success varies widely, from 38% to 100%.6

Retrograde irrigation has a dual purpose: to clean the distal bowel mechanically and to improve rectal reservoir function by distension and improved perception through a defined stimulus. Therefore, a rhythm for sufficient bowel emptying with intervals free of faecal loss is established.

Sacral nerve stimulation

Electrical stimulation of relevant peripheral nerves can recruit residual function of the continence organ. In the last decade, chronic low-frequency stimulation of the sacral spinal nerves (the peripheral nerve supply of the anorectum) gained broad acceptance owing to its efficacy, limited invasiveness and low comorbidity. Its role in the current treatment algorithm became central.5,8

No clinical or physiological predictor of success of chronic stimulation exists, and thus decision-making for implantation of a permanent device is based solely on the outcome of temporary test stimulation, which usually lasts 2 weeks. During this phase, bowel habits are documented with standardized bowel diaries and then compared with pre-test function. Commonly, a 50% improvement in symptoms, defined as episodes of incontinence or days with incontinence episodes, is considered an indication for permanent stimulation. The predictive value is high and, in approximately 90% of patients, the outcome of the test stimulation is at least equalled by permanent stimulation.9,10

The applied technique has become standardized: with percutaneous nerve evaluation (PNE), the sacral spinal nerves S3 and S4 are stimulated with needle electrodes placed through the dorsal sacral foramen. This aims to determine whether or not the single sacral spinal nerve is relevant to the innervation of the striated pelvic floor and anal sphincter muscles and to demonstrate whether or not nerve stimulation can induce muscular contraction.

If PNE is successful, it is followed by the placement of one or more electrodes in the proximity of one or more target spinal nerves. Two techniques are available: (1) temporary electrodes or (2) electrodes that can remain in place for chronic stimulation if this phase is successful. The latter are quadripolar, ‘tined lead’ electrodes and are placed with guidance from fluoroscopy. Both types of electrodes are connected to an external pulse generator for this test stimulation period.

If tined leads have been used and results indicate clinical efficacy, a pulse generator is inserted, usually in a subcutaneous pocket in the gluteal area. If temporary electrodes have been used, the complete neurostimulation system – electrode and pulse generator – needs to be implanted. The chronic stimulation pattern is standardized at 15 Hz, 210 μs, and a continuous or on–off cycle of 5 seconds/1 second with a voltage adapted to the patient’s perception of the stimulation in the anal and perineal region.

With the help of the highly predictive test stimulation, the spectrum of indications has been continuously expanded. Initially, the technique was confined to patients presenting with a weak, but morphologically intact, striated muscle pelvic floor and anal sphincter. Today, sacral nerve stimulation (SNS) is successfully applied to a wide aetiological spectrum including weak external anal sphincter (with or without a deficit or defect of the smooth muscle internal anal sphincter and with or without urinary incontinence), structural defects of the external anal sphincter of up to 180° after rectal resection8,11 and neurogenic incontinence.8 The reproducibility of the clinical efficacy of this technique has been demonstrated in multiple studies (Table 1). With chronic SNS, the frequency of incontinence episodes is reduced, the ability to postpone bowel emptying is increased and the quality of life is improved. In addition, morbidity is low, complications are rare9,10 and long-term follow-up shows sustained efficacy.

TABLE 1

Sacral nerve stimulation for faecal incontinence – studies based on > 50 patients

Author Year Number of patients Mean follow-up (months) Incontinence episodes/week Incontinence score (CCIS)
Pre SNS (baseline) SNS (last follow-up) Pre SNS (baseline) SNS (last follow-up)
Tan et al. 10 2007 53 12 9.5 3.1 16 1.2
Melenhorst et al. 12 2007 100 25.5 10.4 1.5 NA NA
Altomare et al. 13 2009 60 74 3.5 0.7 15 5
Wexner et al. 14 2010 120 28 9.4 1.4 NA NA
Michelsen et al. 15 2010 126 24 8.3 0.6 16 10
Brouwer et al. 16 2010 55 18 NA NA 15‡ 5.2
Gallas et al. 17 2010 200 12a 4‡ NA 14‡ 6.5a
Hollingshead et al. 18 2011 86 33a 8.5 1.3 15 9
Mellgren et al. 19 2011 83 37.2 9.4 1.7 NA NA
Duelund-Jakobsen et al. 20 2011 91 46a 6.3a 0.8a NA NA
Devroede et al. 21 2012 78 > 48 9.4 1.9 NA NA
Damon et al. 22 2013 102 48 NA NA 14 9
Hull et al. 23 2013 76 > 60 9.1 1.7 NA NA
Maeda et al. 24 2013 101 > 60 NA NA 14 8

CCIS, Cleveland Clinic Faecal Incontinence Score (0 = continent, 20 = incontinent); NA, not applicable.

a Median instead of mean.

Adapted from Madoff RD, Laurberg S, Lehur P, et al. Surgery for Faecal Incontinence. In Abrams P, Cardozo L, Khoury S, Wein A (eds.). Incontinence. ICUD-EAU; 2013.5

The mechanism of action of SNS is not fully understood as it is complex and multifactorial. Its effect is not limited to the anorectal continence organ and the large bowel as SNS appears to also affect the part of the central nervous system controlling bowel and sphincter activity.

If the sacral spinal nerves are not accessible for electrode placement or if SNS does not result in sufficient symptom improvement, stimulation of the pudendal nerve at the level of Alcock’s canal is a potential alternative. Two techniques have been described, each as a case report: (1) implantation of a rechargeable stimulator25 and (2) application of a slightly modified SNS system.26

Posterior tibial nerve stimulation

This technique has been adapted from urology. An active electrode is placed close to the posterior tibial nerve, proximal to the medial malleolus. Two different methods are available: (1) percutaneous stimulation with a needle electrode27 and (2) transcutaneous stimulation with surface-adhesive electrodes.28 Adequate placement is confirmed by inducing digital plantar flexion and the ground pad is placed in proximity. A portable pulse generator powers both systems. The stimulation parameters are set arbitrarily, usually 0.2 ms, a current below the threshold for motor response. ranging between 0.5 and 9.0 mA, and a frequency usually 10–20 Hz. Stimulation is intermittent with one or two 30-minute courses per week, declining over subsequent weeks. Currently there is no agreement about the most effective stimulation parameters and protocol.

Short-term posterior tibial nerve stimulation (PTNS) can result in a reduction of incontinence episodes. Inclusion criteria may include idiopathic faecal incontinence,2830 incontinence due to inflammatory bowel disease31 as well as incontinence with internal or external sphincter lesions (or a combination), some after obstetric trauma.29,30,32 PTNS has been applied in treatment of passive, urge and mixed incontinence.33 Symptom improvement has been demonstrated for incontinence after partial spinal injury.34

Current experience with PTNS is still limited and the number of patients treated is small, with only a few larger series published.35,36 The treatment and outcomes reported vary and the follow-up time is often short (Table 2).30,37 Several clinical trials are currently ongoing and larger patient studies are anticipated.

TABLE 2

Posterior tibial nerve stimulation for faecal incontinence – based on current literature and studies with > 10 patients

Author Year Number of patients Mean follow-up (months) Incontinence episodes/week Incontinence score (CCIS) Therapy
Pre PTNS (baseline) PTNS (last follow-up) Pre PTNS (baseline) PTNS (last follow-up)
Percutaneous stimulation
de la Portilla et al. 29 2006 16 8 NA NA 13.2 8.1 4 weeks; 30 minutes per week
Govaert et al. 37 2009 22 12 NA NA 11.6a 5.9 6 weeks; 30 minutes per week
Boyle et al. 30 2010 31 9a NA NA 13 7 12 weeks; 30 minutes per 3–4 days
Findlay et al. 32 2010 13 4 Solid 5, liquid 3 Solid 0, liquid 0 NA NA 12 weeks; 30 minutes per week
George et al. 38 2013 11 6 8.2 1.8 NA NA 6 weeks; two 30=minute sessions per week
Hotouras et al. 35 2013 115 26a NA NA 12.0 9.4 3 months; twelve 30 minute sessions
Transcutaneous stimulation
Queralto et al. 28 2006 10 4 NA NA 11.4 5.4 4 weeks; 20 minutes per day
Vitton et al. 31 2009 12 3a NA NA 14 12 12 weeks; 20 minutes per day
Eléouet et al. 39 2010 32 6 NA NA 14 10 4 weeks; 20 minutes per day
George et al. 38 2013 11 6 7.4 5.2 NA NA 6 weeks; two 30-minute sessions per week
Thomas et al. 40 2013 17 1.5 6 2 NA NA bilateral 6 weeks; 30 minutes per day

CCIS, Cleveland Clinic Faecal Incontinence Score (0 = continent, 20 = incontinent); NA, not applicable.

a Median instead of mean.

Adapted from Madoff RD, Laurberg S, Lehur P, et al. Surgery for Faecal Incontinence. In Abrams P, Cardozo L, Khoury S, Wein A (eds.). Incontinence. ICUD-EAU; 2013.5

Despite the fact that the techniques for SNS and PTNS differ, the concept is comparable. The ‘proof-of-principle’ studies demonstrate a clear reduction in incontinence symptoms. The mechanism of action of PTNS is currently unknown and analogies drawn from findings of physiological changes with SNS have not been explored systematically. However, PTNS has recently gained increasing interest for its minimal invasiveness and low cost.

Reconstructive techniques and anal sphincter augmentation/replacement

Reconstruction, augmentation and replacement of the anal sphincter aim to re-establish function by recreating anatomy. These techniques are utilized if sphincter weakness or lesions of functional relevance are diagnosed, in which case augmentation or reconstruction/replacement would be implemented, respectively. Endoanal ultrasonography serves as the most important diagnostic instrument to determine the presence and extent of a lesion (Figure 1). Whether or not preoperative diagnostic investigation can predict the outcome of surgical intervention remains controversial.

FIGURE 1

Surgical treatment algorithm for faecal incontinence.5

6-3-17-fig1.jpg

Sphincter augmentation

Bioinjectables

The injection of so-called ‘bulking agents’ into the anal sphincter is an adaptation of a urological therapy to increase urethral resistance. In cases of faecal incontinence, the mechanism of action of bioinjectables, enlargement of the haemorrhoidal cushions and filling of sphincter gaps, remains controversial. Internal anal sphincter gaps and internal sphincter degeneration are the most frequent indications. Various substances have been used but only a few have gained broad acceptance. The route of application and the location of the deposits vary depending on the substance; therefore, deposits are placed submucosally or applied intersphincterically by a transanal or trans-sphincteric approach. With silicone-based injectables, endoanal ultrasonography-guided application has resulted in better clinical outcomes than digitally guided application.42 The risk is low with most substances but all available data are limited to the short term. Application can be repeated if efficacy diminishes (Table 3). The ease of use, especially with transanal submucosal application,43 and low risk have sparked increasing interest in this treatment of anal sphincter insufficiency.

TABLE 3

Bioinjectables – studies based on > 70 patients

Author Year Number of patients Mean follow-up (months) Substance Technique Number of injections Volume Success
Tjandra et al. 41 2004 82 6a PTQ Implants® (Uroplasty, Geleen, Netherlands) Intrasphincteric;ultrasonography 4 2.5 ml CCIS with ultrasonography: reduced from 14.5 (baseline) to 3 (follow-up); without ultrasonography: reduced from 14.5 (baseline) to 11 (follow-up)
Bartlett et al. 42 2009 74 28a PTQ Implants Intrasphincteric 4 2.5 ml 70% continent; CCIS = 0: 30%; CCIS reduced from 20 (baseline) to 3.5 (follow-up)
Graf et al. 43 2011 136 6 NASHA/Dx Transanal 4 1 ml 52% had a > 50% of fecal incontinence in the treatment group vs. 31% in the placebo group reduction in incontinent episodes
No difference in CCIS
70 6 Placebo Submucosal Dextranomer in stabilized hyaluronic acid (NASHA/Dx): reduced from 14 (baseline) to 2.5 (follow-up).
Placebo reduced from 13 (baseline) to 1.7 (follow-up)

CCIS, Cleveland Clinic Faecal Incontinence Score (0 = continent, 20 = incontinent).

a Median instead of mean.

Adapted from Madoff RD, Laurberg S, Lehur P, et al. Surgery for Faecal Incontinence. In Abrams P, Cardozo L, Khoury S, Wein A (eds.). Incontinence. ICUD-EAU; 2013.5

In 2011, the injection was used to deliver a self-expanding device to improve anal canal closure. Data are promising, but as yet only preliminary.44 The results of other sphincter augmentation techniques are premature or inconsistent and most series report on small patient numbers.

Magnetic sphincter

The use of a magnetic ring (FENIX™; Torax Medical, Inc., Shoreview, MN, USA) placed around the anal sphincter like a dynamic Thiersch wire for augmentation is in the early stage of development. To adapt to differences in the circumference of the anal sphincter, the ring consists of 14–20 connected magnetic beans that open up in response to a separating force, i.e. passage of bowel content. The advantages of this technique are its relative simplicity and its immediate efficacy. Preliminary outcome data are promising45 but long-term data are pending. The spectrum of indications has not yet been clearly defined and the risk profile and comorbidities are moderate.

Sphincteroplasty

Direct sphincter reconstruction aims to re-establish function by closing a morphological defect by coaptation of the dehiscent muscle. The term sphincter repair is used to describe primary repair of the anal sphincter mechanism immediately after direct trauma. Sphincteroplasty describes a secondary, or delayed, reconstruction of the anal sphincter musculature in either initially unrecognized or initially functionally irrelevant lesions, or if the outcome of primary repair has been unsatisfactory. The most common indication for sphincter repair in obstetrics is childbirth, but in colorectal surgery, it is injury owing to blunt or penetrating trauma. However, most sphincteroplasties reconstruct anterior lesions associated with obstetric injury.

Despite the fact that the results of anal sphincteroplasty are not reported uniformly, outcomes appear to be comparable, with approximately 50% of patients reporting a significant improvement in continence (Table 4). The short-term outcome is not maintained and function deteriorates over time.5759 Nevertheless, a substantial proportion of patients remain satisfied5 and sphincteroplasty can have a lasting effect on quality of life.60

TABLE 4

Sphincteroplasty – studies based on > 70 patients

Authors Year Number of patients Mean follow-up (months) Percentage continent
Londono-Schimmer et al. 46 1994 94 60 50
Gilliland et al. 47 1998 77 24a 55
Karoui et al. 48 2000 74 40 47
Halverson et al. 49 2002 71 27 41
bBravo Gutierrez et al. 50 2004 130 120 6
Norderval et al. 51 2005 71 27 41
Zorcolo et al. 52 2005 93 70a 55
Trowbridge et al. 53 2006 86 67 11
Oom et al. 54 2009 120 111a 38
Gleason et al. 55 2011 74 32 77
cMadoff56 2004 891 NA 66

NA, not applicable.

a Median instead of mean.

b 30/190 available for 10 years follow-up.

c Meta-analysis.

Adapted from Madoff RD, Laurberg S, Lehur P, et al. Surgery for Faecal Incontinence. In Abrams P, Cardozo L, Khoury S, Wein A (eds.). Incontinence. ICUD-EAU; 2013.5

If sphincteroplasty fails to achieve symptom improvement, or if function deteriorates over time, patients can be considered for functional rehabilitation, such as biofeedback and irrigation. Recently, increasing evidence has indicated that SNS may also be a treatment option for patients with sphincter defects after attempted anatomical reconstruction and also as a possible first-line treatment.12,61

Sphincter replacement

Sphincter replacement procedures are recommended if conservative treatment fails, if functional rehabilitation is not successful or if incontinence is the result of a substantial muscular defect that is not suitable for sphincter repair. Two techniques have gained clinical acceptance: (1) dynamic graciloplasty (DGP)62 and (2) the artificial bowel sphincter (ABS).63 The indications for both procedures are similar and both represent an alternative to the creation of a stoma in end-stage faecal incontinence in patients with a substantial muscular and/or neural defect of the anal sphincter complex. In addition, both procedures are invasive and associated with relevant comorbidity.

Dynamic graciloplasty

For DPG, the distal gracilis muscle is harvested with its neuromuscular bundle and positioned to encirlce the anal sphincter.62 This passive sling becomes dynamic by implantation of a neurostimulation device. Two electrodes are positioned in the proximity of the supplying nerve of the transposed muscle. The electrodes are fixed in the muscle and connected to a pulse generator, which is placed subcutaneously in the lower abdominal quadrant.

The applied chronic low-frequency stimulation fulfils two purposes: the gracilis muscle phenotype is transformed from fatigable ‘fast-twitch’ type II muscle fibres to fatigue-resistant ‘slow-twitch’ type I muscle fibres.64 Only after the induced biochemical and physiological changes have taken place is the transposed muscle capable of continuous contraction independent of voluntary effort to ensure increased anal canal closure pressure and serve as a neosphincter. For defecation, the pulse generator is deactivated by telemetry with a handheld programmer to relax the muscle and open the neosphincter.

Short-term and long-term efficacy has been demonstrated repeatedly (Table 5). The therapeutic effect is not limited to an improvement in symptoms; quality of life is also improved. However, functional outcome varies69 with the underlying cause of incontinence: efficacy is lower in patients with pathophysiological conditions associated with sensory deficits than in those with solely structural defects.66

TABLE 5

Dynamic graciloplasty: studies based on > 70 patients

Author Year Number of patients Mean follow-up (months) Percentage continenta
Madoff et al. 65 1999 131 24b 66
Baeten et al. 66 2000 123 23 74
Wexner et al. 67 2002 83 24 53
Rongen et al. 68 2003 200 16.3b 72

a Variable definitions of continence; does not necessarily mean perfect continence.

b Median instead of mean.

Adapted from Madoff RD, Laurberg S, Lehur P, et al. Surgery for Faecal Incontinence. In Abrams P, Cardozo L, Khoury S, Wein A (eds.). Incontinence. ICUD-EAU; 2013.5

Artificial bowel sphincter

The ABS (Acticon Neosphincter®, American Medical Systems, Minneapolis, MN, USA) consists of three components: (1) an inflatable silastic cuff placed around the anus via perianal tunnels, (2) a liquid-filled, pressure-regulating balloon positioned in the preperitoneal fat and (3) a manual pump connecting these, which is placed in either the labia majora or the scrotum.70 The anal canal is closed as the cuff fills with liquid. At the time for defecation, the device is deactivated via the manual pump, the cuff empties and the anus opens to pass stool. The cuff is refilled and the anus is closed after a few minutes.71 A recent, modified artificial anal sphincter (Soft Anal Band®, A.M.I., Feldkirch, Austria)72 follows the same principle of encircling the anus with a cuff for timely and limited opening for defecation. As in DGP, the opening of the anal canal, not the anal closure, becomes the voluntary act and a behaviour comparable to that of a healthy individual. Short-term and long-term efficacy of the ABS has reproducibly been shown, for both incontinence and quality of life (Table 6).63,70,71,75,76

TABLE 6

Artificial bowel sphincter – studies based on > 30 patients

Author Year Number of patients Follow-up (months) Number (%) functioning implant ‘Success’ in patients with functioning device ‘Success’ in intention to treat
Devesa et al. 73 2002 53 26.5 26 (49%) 65% 53%
Wong et al. 63 2002 115 12 75 (65%) 85% 54%
Parker et al. 74 2003 37 39 17 (46%) 49% 47%

Median instead of mean.

Adapted from Madoff RD, Laurberg S, Lehur P, et al. Surgery for Faecal Incontinence. In Abrams P, Cardozo L, Khoury S, Wein A (eds.). Incontinence. ICUD-EAU; 2013.5

The indications and contraindications for DGP and ABS are almost identical: end-stage faecal incontinence with a substantial muscular and/or neural defect (or damage) of the anal sphincter complex and failure of conservative treatment. In distinct conditions, preference should be given to one of the procedures. The success of DGP is dependent on intact innervation of the gracilis muscle. Trophic alterations of the perineal or perianal area carry an increased risk of infection if foreign material is implanted.

The risk of comorbidity in both sphincter replacement procedures is high,69,75,76 with the need for reintervention reaching 42% in DGP77 and 46% in ABS and termination of therapy required in 8% and 32%,76 respectively. Infection is the most severe complication and usually leads to removal of the device. Obstructed defecation can be observed postoperatively, but can usually be treated with conservative means, such as regular retrograde irrigation.

Treatment algorithm

Comparison of the various surgical techniques to treat faecal incontinence is challenging. Outcome measures are heterogeneous and quality-of-life considerations have gained interest only in the last decade. Follow-up data are variable but comparative studies are rare. As a general rule, less invasive procedures should be preferred. In recent years, various techniques of limited invasiveness have been developed. Based on current evidence, the choice of treatment is determined by the presence of a sphincter lesion, e.g. sphincteroplasty is not a meaningful option if no sphincter gap exists. Depending on the efficacy of one technique, a sequential or supplementary use of another technique may be required. It is noteworthy that only the combined use of more than one technique may ultimately result in sufficient symptom improvement.

Competing interests

Professor Matzel is medical adviser to Medtronic EU, Uroplasty, Salix.

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