From the Guidelines
Patients with iatrogenic fecal incontinence are not indicated for percutaneous nerve stimulation as a first-line treatment, and instead, should be considered for sacral nerve stimulation after failing conservative measures and biofeedback therapy, as per the best practice advice 1.
Treatment Options for Iatrogenic Fecal Incontinence
Treatment options for iatrogenic fecal incontinence include both conservative and surgical approaches based on severity and underlying cause.
- Conservative management should be tried first, including dietary modifications (increasing fiber intake to 25-30g daily and avoiding trigger foods like caffeine, alcohol, and spicy foods),
- Pelvic floor muscle training with biofeedback therapy (typically 6-8 weekly sessions),
- Medications such as loperamide (starting at 2mg before meals and titrating as needed) or fiber supplements like psyllium (1 tablespoon daily).
Surgical Options
For more severe cases, surgical options include:
- Sphincteroplasty to repair damaged sphincters,
- Sacral nerve stimulation (particularly effective for sphincter defects),
- Artificial bowel sphincter implantation,
- Or in extreme cases, colostomy. The choice of treatment depends on the specific mechanism of injury, with sphincter damage from obstetric or surgical trauma often benefiting from direct repair, while nerve damage may respond better to sacral nerve stimulation, as suggested by 1.
Best Practice Advice
Best practice advice suggests that sacral nerve stimulation should be considered for patients with moderate or severe FI in whom symptoms have not responded after a 3 month or longer trial of conservative measures and biofeedback therapy and who do not have contraindications to these procedures 1. Percutaneous tibial nerve stimulation should not be used for managing FI in clinical practice, according to best practice advice 1. Treatment should be individualized, starting with the least invasive options and progressing as needed based on symptom improvement and patient quality of life, with the goal of minimizing morbidity, mortality, and improving quality of life, as emphasized by 1.
From the Research
Treatment Options for Iatrogenic Fecal Incontinence
- Iatrogenic fecal incontinence, caused by medical treatment, has various treatment options available, including sacral nerve stimulation (SNS) and percutaneous tibial nerve stimulation (PTNS) 2, 3.
- SNS has been shown to improve continence in selected people with fecal incontinence, although larger, good quality randomized crossover trials are needed to assess its effects with more certainty 2.
- PTNS has emerged as an alternative treatment modality for fecal incontinence, with meta-analysis revealing its superiority in reducing weekly episodes of fecal incontinence compared to sham electrical stimulation 3.
Percutaneous Nerve Stimulation for Fecal Incontinence
- Percutaneous nerve stimulation, including PTNS, has been proposed as a treatment option for fecal incontinence, with some studies showing its effectiveness in reducing symptoms 3, 4.
- However, noninvasive anal electrical and percutaneous tibial nerve stimulation have not been shown to be superior to placebo in controlled trials 5.
- The efficacy of percutaneous nerve stimulation for fecal incontinence needs to be assessed using more stringent criteria to provide a realistic assessment of meaningful efficacy 4.
Indications for Percutaneous Nerve Stimulation
- Patients with iatrogenic fecal incontinence may be indicated for percutaneous nerve stimulation, including PTNS, as a treatment option, especially if conservative measures have failed 6, 4.
- However, the precise indications for percutaneous nerve stimulation remain to be established, and more research is needed to determine its effectiveness and safety in different patient populations 4.