From the Guidelines
For patients with iatrogenic fecal incontinence indicated for overlapping sphincteroplasty, the recommended treatment is overlapping sphincteroplasty, despite its declining success rates over time, as it remains a viable option for restoring anal sphincter function and improving quality of life. When considering treatment options for iatrogenic fecal incontinence, it is essential to weigh the potential benefits and risks of each approach. Overlapping sphincteroplasty is a surgical procedure that involves repairing the damaged anal sphincter complex to restore its function and integrity. According to a study published in Clinical Gastroenterology and Hepatology 1, sphincteroplasty can be performed using an "end-to-end" or "overlap" repair, with post-operative complication rates generally being low.
Key Considerations
- The success rates of overlapping sphincteroplasty decline over time, with one study showing that only 28% of patients were continent at 40 months after the procedure 1.
- Technical and patient-related factors influencing prognosis after sphincteroplasty are not clearly established, making patient selection and comprehensive postoperative care crucial for optimal outcomes.
- Newer modalities with minimally invasive approaches, such as sacral nerve stimulation (SNS), may soon be considered the preferred first-line surgical approach to treatment of fecal incontinence, except in cases with recent or acute sphincter injuries.
Treatment Approach
The recommended treatment approach for overlapping sphincteroplasty involves:
- Preoperative bowel preparation and prophylactic antibiotics to minimize the risk of infection
- Surgical repair of the damaged anal sphincter complex using absorbable sutures
- Postoperative bowel rest, low-residue diet, and stool softeners to prevent straining and promote healing
- Pain management with NSAIDs and opioids as needed
- Physical therapy focusing on pelvic floor exercises to strengthen the repaired muscles and improve sphincter function.
From the Research
Treatment Options for Iatrogenic Fecal Incontinence
The recommended treatment for a patient with iatrogenic fecal incontinence indicated for overlapping sphincteroplasty includes:
- Overlapping sphincteroplasty, which has been shown to be effective in treating fecal incontinence caused by trauma 2
- Biofeedback, which has resulted in a 90% reduction in episodes of incontinence in over 60% of patients 3
- Sacral nerve stimulation, which has shown reasonable short-term effectiveness, but may have complications 4
- Injectable bulking agents, such as dextranomer microspheres in non-animal stabilized hyaluronic acid (NASHA Dx), which have shown significant improvement in incontinence scores and frequency of incontinence episodes 4
Considerations for Treatment
When considering treatment options, it is essential to:
- Evaluate the patient's condition using diagnostic modalities such as anorectal manometry, pudendal nerve latency studies, and electromyography 3
- Assess the severity of incontinence using classification systems such as the Browning-Parks classification or the Wexner score system 2
- Consider the patient's overall health and medical history, as well as the potential risks and benefits of each treatment option 5, 4, 6
Surgical Options
Surgical options, such as overlapping sphincteroplasty, may be considered when conservative therapies are ineffective:
- Overlapping sphincteroplasty has been shown to be effective in treating fecal incontinence caused by trauma, with excellent results achieved in 47.2% of patients and good results in 22.7% of patients 2
- Other surgical options, such as neuromodulation and diversion, may also be considered, depending on the patient's condition and medical history 6