Keynote Lecture: Fecal Incontinence

Fecal Incontinence 

The Cleveland Clinic Foundation 

Cleveland, Ohio 

Tracy L. Hull, M.D. 

Professor of Surgery 

Digestive Disease Institute 

Department of Colorectal Surgery

Several organs in the body were arguing about who was 

the most important 

• The HEART said it was the most important because it 

pumped the blood. 

• The BRAIN ‘thought’ it was the most important 

because it integrated all information and made 

decisions. 

• The EYES ‘viewed’ themselves as the most important 

because they could tell the body where it was going. 

• The KNEES thought they were the most important 

because they carried the body where it wanted to go

• Nobody would listen to the ANAL SPHINCTERS 

• Therefore they shut down 

• After a couple of days of the anus and bowel not 

working properly, the eyes went glassy, the 

knees buckled, the brain turned to jelly, and the 

heart skipped a beat 

• Finally they all said “All right ANAL 

SPHINCTER, you are the BEST.”

• A normally 

functioning anal 

sphincter is a gift 

from GOD 

--anonymous

• Life miserating 

• Evaluating 

improvement after 

treatment is difficult 

as no standard 

definition for severity 

and frequency exists 

• Successful outcome is 

impossible to define 

Fecal Incontinence

Prevalence based on 16 

studies of community 

dwelling adults 

• Anal incontinence 

including flatus 2-24% 

• Anal incontinence 

(excluding flatal) 

0.4-18% 

Macmillan et al DCR 2004 


• Obstetrical injury is 

the most common 

cause of fecal 

incontinence 


Other Causes 

• Surgical trauma (fistulotomy, 

hemorrhoidectomy, sphincterotomy) 

• Irradiation 

• Colitis 

• Rectal prolapse 

• Central nervous system problems 

• Diabetes 

• Scleroderma 

• Medications 

• Others 


Comprehensive History 

• Duration, frequency 

• Quality of stool lost 

• Flatus control 

• Pad use 

• Urgency 

• Affect on daily life 

• Urinary incontinence 

Fecal Incontinence 

• Obstetric history 

• Surgical history 

• Other medical problems 

• Medications 

• Psychosocial 

ramifications of 

incontinence

Physical exam 

• Careful exam of 

perineum, anus, and 

rectum 

Anal ultrasound 

• Preferred tool to map 

sphincters 

• Not always needed but 

may be helpful 


Treatment of Fecal Incontinence 

• Treatment options 

depend on clear 

understanding of 

pathophysiology 

• Standard treatment starts 

with addressing 

underlying conditions

Non-Surgical Treatment: 

forgotten aspects 

• Skin care 

• Barrier creams for 

protection 

• Cotton ball by anus 

• Use of baby wipes 


Fecal Incontinence: Medical Treatment 

• Evaluate and treat diarrhea 

• Biofeedback 

• Anal plug 

• SECCA



• Biofeedback (pelvic floor 

retraining) 

• Anal plug 

• SECCA

Pelvic Floor Retraining: Biofeedback 

• Uses EMG or manometry for visual input 

(auditory or visual cue) 

• Inexpensive (although many insurance 

companies view it as experimental) 

• Painless, easy to perform, does not exclude 

other tx 

• Requires a motivated patient capable of 

understanding the treatment AND 

MOTIVATED THERAPIST

Biofeedback: Protocols 

1. Coordination training— 

contract muscle in response to 

rectal distension 

2. Sensory training—recognize 

smaller volumes of rectal 

contents 

3. Strength training—isolate and 

exercise anal muscle (without 

rectal distention)

Biofeedback: Outcomes 

• N=171 randomized four groups: I) teaching, advice 

and support (a), II) + addition of sphincter exercises 

(a+b), III) +addition of manometric feedback 

(a+b+c), IV) + addition of home training device 

(a+b+c+d) 

• Continence scores, disease-specific and generic QOL 

scores, resting, squeeze, and sustained squeeze 

pressures improved in all groups and improvement 

was maintained at one year 

• Presence and degree of sphincter defect did not 

correlate with outcome 

Norton Gastroenterology 2003

Biofeedback: Outcomes 

• Results vary considerably with reported 

success 38-92% 

• Success does not diminish in most over time 

in few small long term studies (Ryn, Morren 2000) 

• May improve function if symptoms persist 

w/ successful sphincter repair (Jensen, Lowery 1997) 

• No clear patient selection criteria or optimal 

protocol




• Anal plug 

• SECCA




• Anal plug 

• SECCA 

Radio-frequency delivered 

to target temperature of 85 

C for 1 min 23-32 times in 

anal canal

SECCA hand piece 

• Anoscopic barrel 

SECCA: Equipment 

• Light pipe for visualization

SECCA: Procedure 

• Goal is four rows 5 mm 

apart beginning at the 

dentate and moving 

proximal (may opt to 

treat 5 th row) 

• 4 needle treatment per 

quadrant 

• 85 C for 1 min 

• Total 64 lesions

SECCA: How Does it Work? 

• Mechanism of action is unknown 

• “Radiofrequency anal sphincter remodeling” 

(fibroblasts to myoblasts) 

• No consistent changes in anal physiology or 

anal endosonography

SECCA: First Studies 

• Feasibility, safety, 

efficacy 

• N=10 F/U 12 mos 

• Wexner 13.5 to 5 

(p

First 

author 

n F/U 

mos 

SECCA: Results 

Preop 

Wexner 

Efron 

2003 50 6 14 

Lefebure 

2008 

15 12 14 

Ruiz 

2010 24 12 15 

Postop 

Wexner 

11 Multicenter (5) 

prospective all FIQOL sig 

improved 

12 FIQOL only improved 

for depression 

12 FIQOL improved in all 

subsets except depression

SECCA: not all showed improvement 

• N=8 F/U 6 mos 

• FISI and FIQOL showed no improvement 

(except embarrassment scale) 

• 7/8 had anal bleeding, mucous discharge, or 

anal pain 

Kim Am J Surg 2009

SECCA: Complications 

• Bleeding and/or anal pain 10-45% 

• Ulceration in 2/50 after Efron study (2003) 

led to modification of device 

• Potential for rectovaginal fistula 

• Local hematoma 

• The device inserted is large (?? Sphincter 

injury) 

• Don’t use SECCA after injectables 

• No long term complications reported

SECCA: Final Thoughts 

• Consider for Wexner score 

9-17 and

Injectables: Types 

11 injectable bulking agents in the literature 

--- Carbon beads (Durasphere) 

--- Teflon 

--- Silicone (PTQ R ) 

--- Collagen 

--- Calcium hydroxylapatite (Coaptite R ) 

--- Fat 

---Permacol TM 

--- Non-animal Hyaluronic 

Acid with Dextranomer (NASHA TM DX 

[Solesta R ]))

Injectable Agents 

• Injectable stabilized 

hyaluronic acid 

– n=206 randomized double 

blinded sham controlled trial 

– 52% >50 % reduction in FI 

vs 31% control (p=0.0089) 

– One rectal abscess and one 

prostatic abscess 

Graf et al Lancet 2011

Injectables: Results NASH 

• N=34 1 cc x 4 submucosal 

• F/U 12 mos for all patients 

• FI episodes via 4 wk diary 

• Median 10 (r 0-70) 

versus pre 22 (r 2-77) (p=0.004) 

Danielson Dis Colon Rectum 2009

Injectables: Where and How Much 

• 7 different techniques in literature 

– Submucosal or intersphincteric space 

– Route of needle insertion 

• Is ultrasound guidance required 

• One cc in four quadrants 

• Size of needle to implant (21 gauge)

Injectables: Final Thoughts 

• We have minimal evidence-based information 

to guide us regarding injectables 

• Where to inject; what route; how much??? 

• Are laxatives important? 

• Would we improve results if done in OR? 

• RCT with sufficient number of patients 

and longer F/U needed

Fecal Incontinence: Surgical Treatment 

• Overlapping sphincter repair 

• Sacral Nerve Stimulation 

• Artificial bowel sphincter 

• ACE 

• Stoma 

• Not used 

Park’s post anal repair 

Dynamic graciloplasty

Overlapping Sphincter Repair 

• Most common procedure 

for repair of anterior defect 

ADVANTAGES 

• Relatively easy 

• Low cost 

• No fancy equipment needed 

• Can be done globally in any 

OR

Long-term Results of Overlapping Sphincter Repair 

100% 

90% 

80% 

70% 

60% 

50% 

40% 

30% 

20% 

10% 

0% 

St Marks 

2000 n=38 

F/U 77 m 

France 2000 

n=74 

F/U 40 m 

continent 

gas incon 

total incon 

CCF 2002 

n=49 

F/U 69 m 

U of Minn 

2004 n=104 

F/U 120 m 

CCF 2007 

n=41 

F/U 126 m

Long Term Outcome Following 

Overlapping Sphincter Repair 

Why poor long term results? 

• ELUS not done to assess 

adequate initial repair 

• Normal aging of these women’s 

muscles? 

• Some think fibrosis is more 

pronounced in these women and 

affects the results 

• Unrecognized problem in pelvic 

floor

Overlapping Repair: FINAL THOUGHTS 

• Long term results of overlapping sphincter 

repair may not be as good as previously 

assumed 

• Overlapping repair of anterior defect is 

STILL reasonable treatment

Sacral Nerve Modulation 

• 1994 first used for FI 

• FDA approved in US 

• Adapted from use in 

urological disorders 

• Unclear mechanism of 

action

• 9 Fe 1 M 

• PET scan (cerebral blood flow) 

– 30 min after continuous stim 

started 

Sacral Nerve Stimulation 

– repeated 2 weeks after 

continuous stim 

• Initial stim activated contralateral 

frontal cortex normally active in 

focused attention 

Lundby et al Dis Colon Rect 2011


• After 2 wks, activation 

changed to activity in parts of 

ipsilateral caudate nucleus 

(thought to be involved in 

learning and reward) 

• SNS induces changes in 

cerebral activity consistent 

with effect on afferent 

projections of vagus 

Lundby et al Dis Colon Rect 2011


Indications: FI due to 

• Obstetric injury 

• Sphincter defect 

• Anal trauma 

• Cauda equina syndrome 

• Rectal resection 

• Crohn’s disease with sphincter disruption

Phase 1: Test Stimulation

Phase 2: Implantation of 

permanent stimulating device 

to the implanted lead


Meta-analysis of 34 studies: 

• 944 pts with PNE and 665 permanent SNS 

• Weekly episodes FI and incontinence scores 

significantly reduced 

• Ability to defer defecation increased 

•


Meta-analysis of 34 studies: 

• Results similar +/- sphincter defect 

• PNE only predictive test for SNS outcome 

• Complication rate was 15% for permanent SNS w/ 

3% having permanent explantation 

• Most common complications (n=665): Pain (6%), 

lead problem (4%), infection (3%), seroma (3%) 

Tan et al Int J Colorectal Dis 2011


14 studies + 9 with sphincter lesions all pos 

PNE and had permanent implant: 

• 77% improvement idiopathic FI 

• 76% improvement in sphincter defect (17-180 0 ) 

• 78% improvement after OSR 

• 73% improvement w/ neurologic injury 

Matzel Colorectal Dis 2011


14 studies + 9 with sphincter lesions all pos 

PNE and had permanent implant: 

• Sustained benefit at 14 yrs (longest FU) 

• Reduction in clinical efficacy with longterm 

FU in 26% 

Matzel Colorectal Dis 2011


Results EAS defect: 

• EAS defect (21); intact (32) 

• Both had sig improvement QOL 

• Weekly FI 13 to 5 (EAS defect 

p

Sacral Nerve Stimulation Results 

• Pooling data of 8 studies for 238 

• Mean F/U16 mos 

• 88% of these patients reported >50% improvement 

• Complications 5-26% &

Sacral Nerve Modulation Advantages 

Advantages of SNS 

• Done under local + 

sedation 

• Not dependant on 

sphincter morphology 

• Works for SUI , 

? Constipation, ? IBS 

• Good results 

Disadvantages of SNS 

• 30% will not benefit 

• % will not be eligible 

• 5-26% device related 

complications 

• Expensive 

• Cannot be done 

without C arm facility

Acticon Neosphincter 

• Modification of urinary 

sphincter 3 parts: 

1) inflatable cuff 

around anus 

2) central pump (labia 

in Fe; scrotum in M) 

3) regulating balloon 

in Space of Retzius

Consider for: 

Artificial Bowel Sphincter 

• 30 % failed SNS 

• Congenital 

malformation 

• Absent sphincters 

• Significant loss of 

tissue due to injury

• N=52 1996-2010 

• F/U 64 +/- 46.5 mos 

Results of ABS 

• 26 (50%) required revision (most due to 

microperforation) 

• 14 (26.9%) definitive explantation (43% due to 

infection) 

• 35 with active device: fecal incontinence score 

(p

Artificial Sphincter: Complications 

• Range from 23-67% 

• Infection/perineal wound problems 

• Mechanical failure 

• Difficult evacuation 

• Still about 30% after learning curve 

Wong 1996, Lehur 1997, Vaizey 1998, 

Savoye 2000, Lehur 2002, O’Brien 2004

Change in Fecal Incontinence with ABS: 

Lehur 

1998 

Altomare 

2001 

Devasa 

2002 

O’Brien 

2004 

Using Wexner Score 

n preop postop % change 

13 17 4.5 74% 

28 14.9 2.6 83% 

53 17 4.0 74% 

14 19 4.8 89%

Antegrade Colonic Enema (ACE) 

• 1990 Malone 

– for children with neurogenic 

disorders 

• Continent conduit for intermittent 

catheterization 

– Appendix/ cecum/ ileum/ 

descending colon 

• Irrigation of the colon and rapid and 

controlled large bowel purging 

• Does not preclude other future surgery

Antegrade Continence Enema 

• 10 adults F/U 17 mos; 80% 

significant reduction in FI 

episodes 

Malone 1990; Krogh 1998

Fecal Incontinence: Stoma 

• For patients who have failed 

or are not candidates for 

other surgical repairs 

• Old treatment, but can be 

done via a minimally 

invasive approach 

• Allows opportunity to leave 

home, attend work, and 

social functions

Fecal Incontinence: Future 

Magnetic anal encirclement Mesh sling of anus

Posterior Tibial Nerve Stimulation 

• First work for FI from Shafik 

in 2003 (Eur Surg Res) 

• Last 7 yr 7 other studies, all 

from Europe total 129 pts 

• All failed conservative tx 

• Heterogenecity in study pts, 

methodology, and outcomes 

Findlay et al Int J Colorectal Dis 2011; 

Leroi et al Am J Gastroenterol 2012


• All tx protocols vary duration, 

timing, electrical frequency 

but all utilize portable external 

pulse generator 

• Current to post tib nerve 

proximal to medial malleolus 

with needle or adhesive 

electrode 

Findlay et al Int J Colorectal Dis 2011


PTNS protocols: 

• Alt day 20 Hz for 30 min 

• Daily 10 Hz for 20 min 

• Weekly 20 Hz for 30 min 

• Twice wk 20 Hz for 30 min 

• Twice day ?? Hz for 20 min 

Findlay et al Int J Colorectal Dis 2011

90 

80 

70 

60 

50 

40 

30 

20 

10 

0 

Shafik 

'03 n=32 

Summary PTNS trials 

achievement of primary endpoint 

Queralto 

'06 n=10 

Mentes 

'07 n=2 

Vitton 

'09 n=12 

De la 

Portilla 

'09 n=16 

Govaert 

'09 n=22 

Boyle 

'10 n=31 

Findlay 

'10 n=13

Fecal Incontinence: Treatment 

• Optimal treatment regime may 

be complex and tailored 

combination of various surgical 

and non-surgical treatment

Keynote Lecture: Fecal Incontinence

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