Specialty Clinic Referral for Faecal Incontinence

Wesley Lai, MB, ChB, MRCS
Specialist Surgical Registrar National Health Service School of General Surgery
South West Deanery, U.K.

Nicholas J. Kenefick, BChir, MB, MA, MD, FRCS
Member, International Neuromodulation Society
Consultant Colorectal Surgeon, Torbay Hospital, U.K.

Introduction

Faecal incontinence is the uncontrolled passage of faecal material. It is one of the most devastating conditions as it can have a serious impact on one’s quality of life, self-esteem and image, and even lead to social isolation.

Epidemiology

Faecal incontinence is common. In the U.K., one study showed major faecal incontinence affects about 1.4% of the community population over 40 years old¹, while a US survey found faecal soiling occurred in 7% of households². The prevalence of faecal incontinence is likely to be underestimated, as many affected individuals are reluctant to report or discuss it. Also it is more common in the elderly population, with one study reporting faecal incontinence affecting 15% of people 70 years old or older³, and nearly half of the nursing home resident population⁴. It is also the second leading cause of nursing home placement in the U.S.

Causes of Faecal Incontinence

Continence is maintained by a complex process involving the lower alimentary tract and the nervous system; as such the cause of faecal incontinence is often multifactorial. It is dependent on a number of factors including mental function, stool volume and consistency and colonic, rectal and anal sphincter function. Any dysfunction of the above can potentially lead to incontinence. Common causes include obstetric trauma, iatrogenic injury from surgery, faecal impaction particularly among the elderly and multiple medical conditions such as diabetes and inflammatory bowel disease often contribute to the aetiology. When a cause is not identified, it is termed idiopathic faecal incontinence, and it is most common in the middle aged or elderly women.

Clinical Considerations

Assessment of Faecal Incontinence

Assessment requires a detailed medical history and thorough physical examination, followed by appropriate specific investigations. Initially serious colorectal pathology must be excluded, normally by direct visualisation of the colon with colonoscopy.

Once other pathology has been excluded the key factor is an assessment of the severity of symptoms and the impact on the patient’s quality of life.

Essential information required is an accurate obstetric history, details of any previous pelvic or anal surgery or radiotherapy and an accurate medical and current drug history.

Subsequently a number of other specific investigations may be undertaken including anorectal manometry, endoanal ultrasound, proctography and, or a colonic transit study. These focused diagnostic procedures are normally arranged by a specialist clinic in order to pinpoint the underlying cause of faecal incontinence and lead to appropriate management.

Treatment

There are two main treatment options for faecal incontinence: conservative with biofeedback therapy or surgery. It is important to remember that incontinence is a serious symptom but not a life-threatening disease and as such a balance between the severity of symptoms and potential benefit and risks of the treatment needs to be carefully considered in each individual case.

Conservative treatment includes medical treatment with drugs, physiotherapy and lifestyle modification. This includes the use of medication to improve stool consistency and reduce frequency.

Biofeedback therapy is combination of optimising medical treatment, rationalising the degree of severity of symptoms and targeted physiotherapy. There are various techniques but the basic combination of a dedicated trained specialist with the appropriate time to treat patients is essential. Conservative treatment and biofeedback will improve 70-80% of patients to a level where they do not wish any further treatment⁵. It is recommended by the American College of Gastroenterology as a safe and effective treatment for faecal incontinence⁶.

Referral to Specialist Clinic

If conservative measures and biofeedback are unsuccessful referral to a specialist clinic for further investigation and treatment is indicated. Further investigations then aim to identify the underlying cause of the incontinence and the treatment options are then explored. Often further courses of biofeedback may be appropriate. However if symptoms are severe and persistent surgery may be recommended.

Surgery

There are several surgical procedures available for treatment of faecal incontinence. In all cases the potential benefit must be balanced against the risk of the procedure. The current option with the highest chance of success (70%) and with the lowest morbidity is sacral nerve stimulation (SNS). Hence in the vast majority of cases this technique will be trialled first.

Sacral nerve stimulation is a minimally invasive surgical technique that involves low-level chronic electrical stimulation of the sacral nerves to produce the desirable physiological effects. It involves an initial trial with a temporary sacral nerve stimulation device, normally performed as a day case procedure, and then if successful a permanent implant. In 2005 U.K. NICE issued guidelines confirming the safety and efficacy of SNS for faecal incontinence. Economic evaluation had also demonstrated SNS as a cost-effective treatment in the UK NHS⁷. Several studies have shown a long-term success rate of 41-75%⁸.

Other surgical options include an overlapping sphincter repair, a dynamic gracilloplasty and a variety of synthetic anal sphincter devices and injection of various sphincter-bulking materials. These techniques have varying success rates and also varying levels of risk^9,10,11. They tend to be used either after SNS has failed or in specific situations. When all other treatment fails or as a primary treatment in certain situations a colostomy is the treatment of choice. This will cure incontinence and in some situations is an excellent treatment; however it is often declined due to social reasons.

Conclusion

Faecal incontinence is common and can have a devastating effect physically, psychologically and socially. In the majority of cases it is well treated by conservative measures and biofeedback therapy. If symptoms then persist referral to specialist clinic is indicated for specific investigations and specialist treatment. Currently sacral nerve stimulation is the treatment of choice in the majority of cases.

References

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