Sacral Nerve Stimulation for Fecal Incontinence: External Anal Sphincter Defect <Emphasis Type="Italic">vs</Emphasis>. Intact Anal Sphincter

Purpose  This prospective study was designed to assess the effectiveness of sacral nerve stimulation for fecal incontinence in patients with external anal sphincter defect and to evaluate its efficacy regarding presence and size of sphincter defect. Methods  Fifty-three consecutive patients who underwent sacral nerve stimulation for fecal incontinence were divided into two groups: external anal sphincter defect group (n = 21) vs. intact sphincter group (n = 32). Follow-up was performed at 3, 6, and 12 months with anorectal physiology, Wexner’s score, bowel diary, and quality of life questionnaires. Results  The external anal sphincter defect group (defect <90°:defect 90°–120° = 11:10) and intact sphincter group were comparable with regard to age (mean, 63 vs. 63.6) and sex. Incidence of internal anal sphincter defect and pudendal neuropathy was similar. All 53 patients benefited from sacral nerve stimulation. Weekly incontinent episodes decreased from 13.8 to 5 (P < 0.0001) for patients with external anal sphincter defects and from 6.7 to 2 (P = 0.001) for patients with intact sphincter at 12-month follow-up. Quality of life scores improved in both groups (P < 0.0125). There was no significant difference in improvement in functional outcomes after sacral nerve stimulation between patients with or without external anal sphincter defects. Clinical benefit of sacral nerve stimulation was similar among patients with external anal sphincter defects, irrespective of its size. Presence of pudendal neuropathy did not affect outcome of neurostimulation. Conclusions  Sacral nerve stimulation for fecal incontinence is as effective in patients with external anal sphincter defects as those with intact sphincter and the result is similar for defect size up to 120° of circumference. ^†Deceased.     

Sacral Nerve Stimulation is more Effective than Optimal Medical Therapy for Severe Fecal Incontinence: A Randomized,Controlled Study

Purpose This randomized study was designed to compare the effect of sacral neuromodulation with optimal medical therapy in patients with severe fecal incontinence. Methods Patients (aged 39–86 years) with severe fecal incontinence were randomized to have sacral nerve stimulation (SNS group; n = 60) or best supportive therapy (control; n = 60), which consisted of pelvic floor exercises, bulking agent, and dietary manipulation. Full assessment included endoanal ultrasound, anorectal physiology, two-week bowel diary, and fecal incontinence quality of life index. The follow-up duration was 12 months. Results The sacral nerve stimulation group was similar to the control group with regard to gender (F:M = 11:1 vs. 14:1) and age (mean, 63.9 vs. 63 years). The incidence of a defect of ≤ 120° of the external anal sphincter and pudendal neuropathy was similar between the groups. Trial screening improved incontinent episodes by more than 50 percent in 54 patients (90 percent). Full-stage sacral nerve stimulation was performed in 53 of these 54 “successful” patients. There were no septic complications. With sacral nerve stimulation, mean incontinent episodes per week decreased from 9.5 to 3.1 (P < 0.0001) and mean incontinent days per week from 3.3 to 1 (P < 0.0001). Perfect continence was accomplished in 25 patients (47.2 percent). In the sacral nerve stimulation group, there was a significant (P < 0.0001) improvement in fecal incontinence quality of life index in all four domains. By contrast, there was no significant improvement in fecal continence and the fecal incontinence quality of life scores in the control group. Conclusions Sacral neuromodulation significantly improved the outcome in patients with severe fecal incontinence compared with the control group undergoing optimal medical therapy. *Deceased. Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, June 2 to 6, 2007.     

Sacral Nerve Stimulation for Fecal Incontinence Following Surgery for Rectal Prolapse Repair: A Multicenter Study

PURPOSE: A proportion of patients have fecal incontinence secondary to a full-thickness rectal prolapse that fails to resolve following prolapse repair. This multicenter, prospective study assessed the use of sacral nerve stimulation for this indication. METHODS: Patients had to have more than or equal to four days with fecal incontinence per 21-day period more than one year after surgery. They had to have failed conservative treatment and have an intact external anal sphincter. RESULTS: Four female patients aged 42, 54, 68, and 65 years met the inclusion criteria. Three of the four patients had had more than one operation for recurrent full-thickness rectal prolapse before sacral nerve stimulation, one of whom had undergone a further operation for recurrence following stimulation. One patient had undergone one operation for prolapse repair. The preoperative duration of symptoms was ten, eight, three, and nine years, respectively. Although patients had an intact external anal sphincter, one patient had a fragmented internal anal sphincter. The frequency of fecal incontinent episodes changed from 11, 24.7, 5, and 8 per week at baseline to 0, 1.5, 5.5, and 1 per week at latest follow-up. Ability to defer defecation was also improved in two of three patients who had this documented. Fecal incontinence-specific quality of life assessment showed an improvement in all four domains. CONCLUSION: Sacral nerve stimulation should be considered for patients with ongoing fecal incontinence following full-thickness rectal prolapse repair if they prove resistant to conservative treatment.     

Sacral Nerve Stimulation can Improve Continence in Patients with Crohn’s Disease with Internal and External Anal Sphincter Disruption

Purpose  Sacral nerve stimulation is a technique commonly used for the treatment of idiopathic incontinence. This study was designed to assess the efficiency of sacral nerve stimulation as a means of treating fecal incontinence in patients with Crohn’s disease with disrupted internal and external anal sphincters. Methods  Five patients (3 women) with fecal incontinence suffering from Crohn’s disease-related anoperineal lesions were treated by applying three weeks of sacral nerve stimulation and then by permanent sacral nerve stimulation implantation. Endoanal ultrasonography showed that all of these patients had disrupted external and internal anal sphincters. Results  Continence was improved in all treated patients. The median follow-up time was 14 (range, 3–36) months. At the end of the follow-up period, the median Wexner’s score significantly improved from 15 to 6 and the median number of daily stools decreased from 7 to 2. The patients’ quality of life also increased significantly. Conclusions  Sacral nerve stimulation improves fecal continence in patients suffering from Crohn’s anoperineal lesions with internal and external anal sphincters disruption. Address of correspondence: Veronique Vitton, M.D., Service de gastroenterologie, H?pital Nord, Chemin des Bourrely, 13915 Marseille, Cedex 20, France. E-mail: veronique.vitton@mail.ap-hm.fr     

Overt Rectal Prolapse and Fecal Incontinence

PURPOSE  Rectal prolapse is frequently associated with fecal incontinence; however, the relationship is questionable. The study was designed to evaluate fecal incontinence in a large consecutive series of patients who suffered from rectal prolapse, focusing on both past history, anal physiology, and imaging. METHODS  Eighty-eight consecutive patients who suffered from an overt rectal prolapse (72 women, 16 men; mean age, 51.1 ± 19.5 years) as a main symptom were analyzed; 48 patients also experienced fecal incontinence compared with 40 without incontinence. Logistic regression analyses were performed. RESULTS  The two groups of patients did not differ with respect to parity, weekly stool frequency, main duration of symptoms before referral, occurrence of dyschezia, and digital help to defecate. Patients with prolapse who were older than 45 years (odds ratio (OR), 4.51 (1.49–13.62); P = 0.007) and those with a past history of hemorrhoidectomy (OR, 9.05 (1.68–48.8); P = 0.01) were significantly more incontinent. Incontinent group showed frequent internal anal sphincter defect compared with the continent group (60 vs. 6.2 percent; P = 0.0018). CONCLUSIONS  In patients with overt rectal prolapse, the occurrence of fecal incontinence needs special consideration for age and previous hemorrhoid surgery as causative factors. Anal weakness and sphincter defects are frequently observed.     

Rectal Volume Tolerability and Anal Pressures in Patients With Fecal Incontinence Treated With Sacral Nerve Stimulation

Purpose Sacral nerve stimulation has proven to be a promising treatment for fecal incontinence when conventional treatment modalities have failed. There have been several hypotheses concerning the mode of action of sacral nerve stimulation, but the mechanism is still unclear. This study was designed to evaluate the results of rectal volume tolerability, rectal pressure-volume curves, and anal pressures before and six months after permanent sacral nerve stimulation and to investigate the mode of action of sacral nerve stimulation. Methods Twenty-nine patients with incontinence (male/female ratio = 6/23; median age, 58 (range, 29–79) years) underwent implantation of a permanent sacral electrode and neurostimulator after a positive percutaneous nerve evaluation test. Wexner incontinence score, rectal distention with thresholds for “first sensation,” “desire to defecate,” and “maximal tolerable volume,” rectal pressure-volume curves, anal resting pressure, and maximum squeeze pressure were evaluated at baseline and at six months follow-up. Results Median Wexner incontinence score decreased from 16 (range, 6–20) to 4 (range, 0–12; P < 0. 0001). Median “first sensation” increased from 43 (range, 16–230) ml to 62 (range, 4–186) ml (P = 0.1), median “desire to defecate” from 70 (range, 30–443) ml to 98 (range, 30–327) ml (P = 0.011), and median “maximal tolerable volume” from 130 (range, 68–667) ml to 166 (range, 74–578) ml (P = 0.031). Rectal pressure-volume curves showed a significant increase in rectal capacity (P < 0.0001). The anal resting pressure increased significantly from 31 (range, 0–109) cm H₂O to 38 (range, 0–111) cm H₂O (P = 0.045). No significant increase in maximum squeeze pressure was observed. Conclusions For patients with fecal incontinence successfully treated with sacral nerve stimulation, there was a significant increase in rectal volume tolerability and rectal capacity. A significant increase in anal resting pressure, but not in maximum squeeze pressure, was found. We suggest that sacral nerve stimulation causes neuromodulation at spinal level. Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, April 30 to May 5, 2005.     

Sacral nerve stimulation for treatment of fecal incontinence

PURPOSE: Many patients with fecal incontinence demonstrate a functional deficit of the internal anal sphincter or the external sphincter muscles without any apparent structural defects. Few patients are amenable to repair or substitution of the sphincter. However, sacral nerve stimulation appears to offer a valid treatment option for fecal incontinence. The objectives of this study were: to evaluate the efficacy of temporary stimulation of the sacral nerve roots (percutaneous nerve evaluation) in patients with functional fecal incontinence; to determine the mechanisms of possible improvement; and to evaluate if temporary stimulation could be reproduced and maintained by implanting a permanent neurostimulation system. METHODS: Twenty-three patients with fecal incontinence, 18 females and 5 males, median age of 54.9 years (range 28–71), underwent a percutaneous nerve evaluation test. Eleven patients (47.8 percent) also had urinary disorders: urge incontinence (4), stress incontinence (3), and retention (4). Associated disorders included perineal and rectal pain (1), spastic paraparesis (1), and syringomyelia (1). All patients underwent a preliminary evaluation using stationary anal manovolumetry, pudendal nerve terminal motor latency measurements, and anal ultrasound. A percutaneous electrode for the stimulation of the sacral nerve roots was positioned at the level of the third sacral foramen (S3) in 20 patients and S2 in 2 patients (1 patient missing). Stimulation parameters used were: pulse width 210µsec, frequency 25 Hz, and average amplitude of 2.8 V (range 1–6). The electrode was left in place for a minimum of 7 days. Five patients were successively implanted with a permanent sacral electrode with a stimulation frequency of 16 to 18 Hz and amplitude of 1.1–4.9 V. RESULTS: Seventeen of the 19 patients (89.4 percent) who completed the minimum percutaneous nerve evaluation period of 7 days (median 10.7 (range 7–30)), had a reduction of liquid or solid stool incontinence by more than 50 percent, and fourteen (73.6 percent) were completely continent for stool. The most important changes revealed by manovolumetry were an increase in resting pressure (P<0.001) and voluntary contraction (P=0.041), reduction of initial pressure for first sensation (P=0.049) and urge to defecate (P=0.002), and a reduction of the rectal volume for urge sensation (P=0.006). The percutaneous nerve evaluation results were reproduced at a median follow-up of 19.2 months (range 5 to 37) in the 5 patients who received a permanent implant. CONCLUSIONS: Temporary stimulation of the sacral roots (percutaneous nerve evaluation) can be of help in those patients with fecal incontinence, and the results are reproduced with permanent implantation. The positive effect on continence seems to be derived from not only the direct efferent stimulation on the pelvic floor and the striated sphincter muscle, but also from modulating afferent stimulation of the autonomous neural system, inhibition of the rectal detrusor, activation of the internal anal sphincter, and modulation of sacral reflexes that regulate rectal sensitivity and motility.     

A pilot assessment of whether external coil MRI is useful to assess evacuatory disorders

This study assessed the value of common surface coil mag-netic resonance imaging (MRI) in patients with evacuatory disorders including fecal incontinence and constipation. These findings were then compared with those from other standard physiological examinations and/or surgical findings. From July 1996 to June 1997, 14 consecutive patients underwent surface coil MRI for evaluation of either fecal incontinence (n=5) or constipation (n=9). In patients with incontinence we compared the findings from endoanal ultrasound (EAUS), anal MRI, and surgery regarding morphopathological findings of the internal and external anal sphincter components. In constipated patients the findings of videoprography and dynamic pelvic MRI were compared regarding the presence of rectocele, rectoanal intussusception, and sigmoidocele as well as the measurements of anorectal angle and perineal descent. The five incontinent patients were all women, with a median age of 67 years (range 43–77). EAUS revealed an anterior sphincter defect in two patients, a posterior defect in one, and normal anal sphincter images in two. Surgical findings confirmed an anterior external anal sphincter scar in two patients, an internal anal sphincter defect in one, and an anatomically normal anal sphincter in two. In one patient, although anal MRI showed posterior external anal sphincter defect, EAUS and surgery revealed normal external anal sphincter appearance. The accuracy rate between EAUS and anal MRI was only 20%, that between surgery and anal MRI 40%, and that between surgery and EAUS 80%. Thus EAUS was more accurate than anal MRI in incontinent patients. The nine constipated patients were all women, with a mean age of 59 years (range 40–78). Videoproctography revealed an anterior rectocele in six patients, rectoanal intussusception in three, and sigmoidocele in five; no abnormalities were identified in two patients. On dynamic pelvic MRI anterior rectocele was seen in three patients and sigmoidocele in two, and five studies were interpreted as normal. One of the patients underwent sigmoidectomy for sigmoidocele, and five patients were treated by biofeedback. Thus the accuracy rate of dynamic pelvic MRI against videoproctography was 60% for anterior rectocele, 40% for sigmoidocele, and zero for rectoanal intussusception. In conclusion, neither MRI for the evaluation of patients with fecal incontinence nor for the evaluation of patients with constipation added any significant information that would warrant its continued use in these patient groups. Perhaps the more widespread availability of an endoanal coil will alter this conclusion; however, at the present time we cannot routinely endorse the expense, time, or inconvenience of these MRI investigations in patients with these diagnoses. Larger prospective comparative studies are required prior to endorsing the technique. Accepted: 21 February 2000     

Sacral nerve neuromodulation improves physical,psychological and social quality of life in patients with fecal incontinence

There are several therapeutic options for fecal incontinence but often they do not achieve good results in the long run. This study dealt with sacral nerve modulation, a new therapeutic option. Twenty-one patients underwent pudendal nerve evaluation (PNE) at our institution. Nine patients were affected by both fecal and urinary incontinence, 3 had fecal incontinence and anal pain, 5 had fecal incontinence and pelvic floor dyssynergia, and 4 had isolated fecal incontinence. They underwent morphological, functional and psychological tests prior to PNE, showing no sphincter rupture, almost normal anal pressures, impaired rectal sensation and deficient psychological pattern. All patients underwent at least two nerve evaluations. Four of 21 patients (19%) were selected to receive a permanent sacral electrode, as PNE seemed to have improved their symptoms by >75%. A median follow-up of 15 months (range, 6–24 months) showed that this method decreases weekly episodes of incontinence and increases maximal squeeze pressure. We demonstrated an increase in basal pressure in 3 of 4 patients (all with isolated fecal incontinence). Rectal sensation threshold decreased in three patients; urge threshold decreased in two patients and increased in two patients, but in each patient we got a stabilization. We evaluated the quality of life by applying the Short Form Health Survey test (SF-36). All 4 patients showed a significant increase in the scores of physical, emotional and social role functioning after the permanent implant. In conclusion, sacral nerve modulation may improve physical, physiological and social quality of life in selected groups of incontinent patients without gross sphincter lesions and with impaired rectal sensation. Received: 6 June 2002 / Accepted: 10 November 2002     

A Prospective,Randomized Study: Switch Off the Sacral Nerve Stimulator During the Night?

Purpose Sacral nerve stimulation is an effective treatment for fecal incontinence. Some have recommended to “switch off” the pacemaker during the night to extend the lifetime of the expensive pacemaker. This study was designed to investigate whether a nightly “switch off” affects the clinical results of sacral nerve stimulation. Methods Twenty patients successfully treated with sacral nerve stimulation (19 females; median age, 59 (range, 36–72) years) were randomized to: Group A, pacemaker continuously “on” for three weeks followed by three weeks with the pacemaker “off” during the night, or Group B, opposite order. Daily bowel-habit diary, Wexner, and St. Mark’s incontinence scores were obtained. Results One failed to return the daily bowel-habit diary, leaving 19 participating patients. Median Wexner incontinence score increased from 6 (range, 2–14) to 7 (range, 3–16) during the “off” period (P = 0.04), whereas St. Mark’s incontinence score increased from 10 (range, 3–16) to 11 (range, 3–18; P = 0.03). Median number of days with soiling per three weeks increased from 0 (range, 0–12) to 1 (range, 0–15) during the “off” period (P = 0.008). Seven of 19 had more days with soiling during the “off” period. Defecation frequency per three weeks increased from 26 (range, 11–71) to 34 (range, 9–70) during the “off” period (P = 0.19). Only four continued with a nightly “switch off” after the study. Conclusions It could be considered to recommend compliant patients to “switch off” the pacemaker during the night to extend the lifetime of the pacemaker. One-third experienced increased soiling, and they should turn the pacemaker on all day and night. Among the remaining, only a minor proportion will be motivated for turning the pacemaker off. Read at the meeting of the European Society of Coloproctology, Malta, September 26 to 29, 2007.     

Clinical outcome of anterior overlapping external anal sphincter repair with internal anal sphincter imbrication

Fecal incontinence caused by overt anterior sphincter defects sustained during childbirth is usually treated by a delayed overlapping repair of the external anal sphincter. However, an obstetric trauma is frequently associated with disruption of the perineal body and loss of the distal rectovaginal septum. Data regarding a combined repair, consisting of restoration of the rectovaginal septum and perineal body, overlapping external anal sphincter repair, and imbrication of the internal anal sphincter, are scanty. PURPOSE: This prospective study was aimed at the following: 1) evaluating the clinical outcome of such an anterior anal repair in patients with fecal incontinence caused by obstetric trauma; 2) comparing the functional results with those obtained in a historical group of patients who underwent a conventional direct sphincter repair. METHODS: During the period between 1973 and 1989, 24 female patients (median age, 44 (range, 28–67) years) with fecal incontinence underwent direct sphincter repair (Group I). During the period between 1989 and 1994, a consecutive series of 31 female patients (median age, 46 (range, 23–78) years) with fecal incontinence underwent anterior anal repair (Group II). RESULTS: At two years of follow-up, continence had been restored in 15 patients (63 percent) in Group I, whereas restoration of continence was successful in 21 patients (68 percent) in Group II. CONCLUSION: The more complex anterior anal repair fails to confer clinical benefit compared with the rather simple direct sphincter repair.Read at the meeting of The American Society of Colon and Rectal Surgeons, Montreal, Quebec, Canada, May 7 to 12, 1995.     

Cholestyramine—a useful adjunct for the treatment of patients with fecal incontinence

Aim/Background Cholestyramine may improve fecal incontinence, but its use has not been assessed. We report our experience with the use of cholestyramine in the treatment of fecal incontinence. Materials and methods Twenty-one patients (19 female, mean age 65 years) with fecal incontinence (≥1 episode/week) received cholestyramine along with biofeedback therapy (group A). Stool frequency, stool consistency (Bristol scale), number of incontinent episodes, satisfaction with bowel function (VAS), and anorectal physiology were assessed at 3 months and at 1 year after treatment. Data were compared with a matched group of 21 incontinent subjects (19 female, mean age 64 years) who received biofeedback alone (group B). Results At 3 months and at 1 year, group A patients showed decreased stool frequency (p < 0.01), stool consistency (p = 0.001), and number of incontinent episodes (p < 0.04). In contrast, stool frequency (p = 0.8) and stool consistency (0.23) were not different from baseline in group B subjects. In both groups, there was improvement in the satisfaction with bowel function (p < 0.05), anal sphincter pressures (p < 0.05) and ability to retain saline infusion (p < 0.05). Mean dose of cholestyramine used was 3.6 g; 13 subjects (62%) required dose titration, and 7 (33%) subjects reported minor side effects. Conclusion Cholestyramine is safe and useful adjunct for the treatment of diarrhea and fecal incontinence. Most patients require small doses, and dose titration is important. The improvement in stool characteristics favors a drug effect, over and above the benefits of biofeedback therapy. Portions of this work were presented at the 2006 American College of Gastroenterology Meeting, Las Vegas, Nevada and published as an abstract in Am J Gastroenterol 2006; 101 (Suppl):S210–S211.     

Sacral Nerve Stimulation Can Be Successful in Patients With Ultrasound Evidence of External Anal Sphincter Disruption

PURPOSE This study was designed to determine whether patients with fecal incontinence and endoanal ultrasound evidence of anal sphincter disruption may be successfully treated by sacral nerve stimulation.METHODS Five consecutive females with incontinence to solids and endoanal ultrasound evidence of anal sphincter disruption were treated by a two-week trial of sacral nerve stimulation. If successful, patients then proceeded to permanent sacral nerve stimulation implantation.RESULTS Five patients, aged 34 to 56 years, were treated by temporary sacral nerve stimulation. Four had symptoms starting after childbirth. Two had previously had an anterior sphincter repair. After a two-week trial, three females reported full continence and an improvement in all aspects of their Rockwood fecal incontinence quality of life scores. These three females underwent permanent sacral nerve stimulation implantation. The remaining two patients reported no improvement and underwent dynamic graciloplasty or end colostomy respectively.CONCLUSIONS Sacral nerve stimulation may successfully restore bowel continence in some patients with endoanal ultrasound evidence of a defect in their external anal sphincter.     

Anal sphincter repair in patients with obstetric trauma

PURPOSE: This study was designed to determine whether advancing age affects the outcome of anal sphincter repair in patients with obstetric trauma and fecal incontinence. METHODS: Anal sphincter repair was performed on 24 patients younger than 40 (median age, 30) years and on 14 patients older than 40 (median age, 57) years. All patients had previous obstetric trauma. RESULTS: Twenty patients younger than 40 years (83 percent; 95 percent confidence interval, 63–95 percent) became continent, or incontinent to flatus only, after anal sphincter repair, whereas four patients had unchanged incontinence. Among patients older than 40 years, six patients (43 percent; 95 percent confidence interval, 18–71 percent) became continent, whereas eight patients remained incontinent (40 percent difference in functional outcome between younger and older patients; 95 percent confidence interval, 10–70 percent). CONCLUSION: Older females have a poorer outcome of anal sphincter repair for obstetric trauma compared with younger females.     

Sacral Nerve Stimulation in Fecal Incontinence

PURPOSE: The effect of sacral nerve stimulation was studied in 45 patients with fecal incontinence.METHODS: All patients were initially tested in general anesthesia. Sacral nerves 2, 3, and 4 were tested on both sides. If a perineal/perianal muscular response to sacral nerve stimulation could be obtained, electrodes were implanted for a three-week test-stimulation period. If sacral nerve stimulation resulted in at least a 50 percent reduction in incontinence episodes during the test period, a system for permanent sacral nerve stimulation was implanted.RESULTS: When tested in general anesthesia, 43 of 45 patients had a muscular response to sacral nerve stimulation and had electrodes implanted for the three-week test period. Percutaneous electrodes were used in 34 patients, and 23 of these had at least a 50 percent reduction in incontinence episodes, whereas the electrodes dislocated in 7 patients and 4 had a poor response. Permanent electrodes with percutaneous extension electrodes were used primarily in 9 patients and after dislocation of percutaneous electrodes in an additional 6 patients; 14 of these had a good result. In the last patient, no clinical response to stimulation with the permanent electrode could be obtained. A permanent stimulation system was implanted in 37 patients. After a median of six (range, 0–36) months follow-up, five patients had the system explanted: three because the clinical response faded out, and two because of infection. Incontinence score (Wexner, 0–20) for the 37 patients with a permanent system for sacral nerve stimulation was reduced from median 16 (range, 9–20) before sacral nerve stimulation to median 6 (range, 0–20) at latest follow-up (P < 0.0001). There was no differences in effect of sacral nerve stimulation in patients with idiopathic incontinence (n = 19) compared with spinal etiology (n = 8) or obstetric cause of incontinence (n = 5). Sacral nerve stimulation did not influence anal pressures or rectal volume tolerability.CONCLUSIONS: Sacral nerve stimulation in fecal incontinence shows promising results. Patients with idiopathic, spinal etiology, or persisting incontinence after sphincter repair may benefit from this minimally invasive treatment.Presented at the meeting of The American Society of Colon and Rectal Surgeons, New Orleans, Louisiana, June 21 to 26, 2003.Reprints are not available.     

Long-Term Outcome of Delayed Primary or Early Secondary Reconstruction of the Anal Sphincter after Obstetrical Injury

Purpose Traditionally sphincter repair has not been performed during the puerperium. This prospective study was designed to determine the long-term outcome of delayed primary or early secondary sphincteroplasty in the puerperium. Methods Between 1991 and 2005, 22 females underwent delayed primary or early secondary repair after third-degree or fourth-degree anal sphincter rupture. Delayed primary reconstruction was performed more than 72 hours after delivery. Early secondary reconstruction was performed within 14 days postpartum. The reconstruction of the anal sphincter was performed without a covering stoma, in all cases. A control group of 19 age-matched and parity-matched females, without known anal sphincter injury after vaginal delivery, were included. Current degree of continence and associated quality of life were determined by a fecal incontinence severity questionnaire and a quality of life questionnaire. Results None of the females had complications postoperatively. Mean follow-up was 50 (range, 2–155) months in the case group and 60 (range, 12–132) months in the control group. At time of follow-up, the Wexner score was 4.1 (range, 0–13) in females with delayed primary or early secondary reconstruction and 1.1 (range, 0–8) in the control group (P < 0.01). The inconvenience of incontinence after reconstruction was significantly higher (P < 0.01) compared with the control group, but the quality of life was not significantly affected (P = 0.75). Conclusions It is safe to perform a delayed primary or early secondary reconstruction without a covering stoma in females who have sustained a third-degree or fourth-degree obstetric tear. The long-term functional outcome is acceptable. Poster presentation at the meeting of European Society of Coloproctology (ESCP), Lisbon, Portugal, September 13 to 16, 2006.     

Anorectal pressure gradient and rectal compliance in fecal incontinence

To study whether anorectal pressure gradients discriminated better than standard anal manometry between patients with fecal incontinence and subjects with normal anal function, anorectal pressure gradients were measured during rectal compliance measurements in 36 patients with fecal incontinence and in 22 control subjects. Anal and rectal pressures were measured simultaneously during the rectal compliance measurements. With standard anal manometry, 75% of patients with fecal incontinence had maximal resting pressure within the normal range, and 39% had maximum squeeze pressure within the normal range. Anorectal pressure gradients did not discriminate better between fecal incontinence and normal anal function, since, depending on the parameters used, 61%–100% of the incontinent patients had anorectal pressure gradients within the normal range. Patients with fecal incontinence had lower rectal volumes than controls at constant defecation urge (median 138 ml and 181 ml, P<0.05) and at maximal tolerable volume (median 185 ml and 217 ml, P<0.05). We conclude that measurements of anorectal pressure gradients offer no advantage over standard anal manometry when comparing patients with fecal incontinence to controls. Patients with fecal incontinence have a lower rectal volume tolerability than control subjects with normal anal function. Accepted: 5 June 1998     

Do internal anal sphincter defects decrease the success rate of anal sphincter repair?

Background Anatomic anal sphincter defects can involve the internal anal sphincter (IAS), the external anal sphincter (EAS), or both muscles. Surgical repair of anteriorly located EAS defects consists of overlapping suture of the EAS or EAS imbrication; IAS imbrication can be added regardless of whether there is IAS injury. The aim of this study was to assess the functional outcome of anal sphincter repair in patients intraoperatively diagnosed with combined EAS/IAS defects compared to patients with isolated EAS defects. Methods The medical records of patients who underwent anal sphincter repair between 1988 and 2000 and had follow-up of at least 3 months were retrospectively assessed. Fecal incontinence was assessed using the Cleveland Clinic Florida incontinence score wherein 0 equals perfect continence and 20 is associated with complete incontinence. Postoperative scores of 0–10 were interpreted as success whereas scores of 11–20 indicated failure. Results A total of 131 women were included in this study, including 38 with combined EAS/IAS defects (Group I) and 93 with isolated EAS defects (Group II). Thirty-three patients (87%) in Group I had imbrication of a deficient IAS, compared to 83 patients (89%) in Group II. All patients had either overlapping EAS repair (n=121) or EAS imbrication (n=10). Mean follow-up was 30.9 months (range, 3–131 months). There were no statistically significant differences between the two groups relative to age (48.3 vs. 53.0 years; p=0.14), preoperative incontinence score (16.1 vs. 16.7; p=0.38), extent of pudendal nerve terminal motor latency pathology (left, 11.1% vs. 8%; p=0.58; right, 8.6% vs. 15.1%; p=0.84), extent of pathology at electromyography (54.8% vs. 60.1%; p=0.43), and length of follow-up (26.9 vs. 32.5 months; p=0.31). The success rates of sphincter repair were 68.4% for Group I versus 55.9% for Group II (p=NS). Both groups were well matched for incidence of IAS imbrication as well as age, follow-up interval, and physiologic parameters. The success rates of anal sphincter repair were not statistically significant between the two groups. Conclusion A pre-existing IAS defect does not preclude successful sphincteroplasty as compared to repair of an isolated EAS defect. Thus, patients with combined anal sphincter defects should not be considered as poor candidates for sphincter repair. Presented in part at the annual meeting of the Association of Coloproctology of Great Britain and Ireland, 2–5 July 2002, Manchester, UK.     

Fecal Incontinence in Females With a Past History of Vaginal Delivery

PURPOSE: The aim of this study was to determine the significance of anal sphincter defects detected by ultrasonography, in a population of fecal incontinent parous females without previous anoperineal surgery. METHODS: From 100 consecutive incontinent patients, 61 females with at least one previous vaginal delivery and no past anoperineal surgery were studied. The severity of fecal incontinence was assessed by the Cleveland Clinic questionnaire score. Lesions of the internal or external anal sphincters, and the radial size of these defects were assessed by ultrasonography. Anal vector manometry was performed to measure anal pressures at rest and during voluntary squeeze, and the anal asymmetry index. RESULTS: Twenty-three had a normal sphincter (38 percent), and 38 (62 percent) had a defect detected by ultrasonography: 20 isolated defects of the external sphincter and 18 combined defects of the internal and external sphincters. Combined defects were significantly larger. The radial size of the defects was positively correlated with the severity of clinical symptoms. Anal pressure asymmetry index was significantly increased in the group with combined defects compared with the two other groups. An index of 25 percent or greater had a very high (100 percent) negative predictive value for the presence of a defect larger than 90°. CONCLUSIONS: This study confirms the high prevalence of anal sphincter defects detected by ultrasonography in a population of incontinent parous females without previous proctologic surgery. The clinical symptoms are related to the size of these defects. Anal vector manometry may be a useful tool to confirm the relation between echographic anal sphincter lesions and fecal incontinence.     

The artificial bowel sphincter for faecal incontinence: a single centre study

Background and aims Faecal incontinence (FI) is a socially devastating problem. The treatment algorithm depends on the aetiology of the problem. Large anal sphincter defects can be treated by sphincter replacement procedures: the dynamic graciloplasty and the artificial bowel sphincter (ABS). Materials and methods Patients were included between 1997 and 2006. A full preoperative workup was mandatory for all patients. During the follow-up, the Williams incontinence score was used to classify the symptoms, and anal manometry was performed. Results Thirty-four patients (25 women) were included, of which, 33 patients received an ABS. The mean follow-up was 17.4 (0.8–106.3) months. The Williams score improved significantly after placement of the ABS (p < 0.0001). The postoperative anal resting pressure with an empty cuff was not altered (p = 0.89). The postoperative ABS pressure was significantly higher then the baseline squeeze pressure (p = 0.003). Seven patients had an infection necessitating explantation. One patient was successfully reimplanted. Conclusion The artificial bowel sphincter is an effective treatment for FI in patients with a large anal sphincter defect. Infectious complications are the largest threat necessitating explantation of the device.