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Treatment for Fecal Incontinence: Neuromodulation

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Female Pelvic Medicine

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Abstract

Sacral neuromodulation (SNM) has revolutionized the treatment of moderate-to-severe fecal incontinence by essentially providing relief without direct manipulation of the anal sphincter. The minimally invasive technique, potential long-term outcomes, and high safety profile makes it an attractive option for many patients. We explore the evolution, trends, and long-term outcomes in patients undergoing treatment with SNM.

Commentary by Tracy L. Hull, Cleveland Clinic, Department of Colon and Rectal Surgery, Cleveland, OH, USA

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Author information

Authors and Affiliations

  1. University of Miami, Department of General Surgery, Division of Colorectal Surgery, Miami, FL, USA

    Vanessa W. Hui

  2. Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA

    Giovanna da Silva

Authors
  1. Vanessa W. Hui
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  2. Giovanna da Silva
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Correspondence to Giovanna da Silva .

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Editors and Affiliations

  1. Department of Urology, Virginia Mason Medical Center, Seattle, WA, USA

    Kathleen C. Kobashi

  2. Cleveland Clinic Florida, Weston, FL, USA

    Steven D. Wexner

Commentary

Commentary

  • Tracy L. Hull 

Fecal incontinence (FI), although not life threatening, can be a devastating condition. The anguish unleashed from the fear of FI can lead to social isolation and emotional desolation. The etiology of FI is multifactorial, and treatment must be individualized and based on a careful history, physical exam, and selected testing [53]. Many factors influence the ability to control stool and gas. These include diet, stool consistency, other bowel surgery, injury, and other unknown factors. Most treatment starts with diet manipulation, reducing diarrhea, and physical therapy training (biofeedback) [53]. However, while these treatments can improve FI, in many instances, it does not result in sufficient reduction to alleviate the anguish of FI. Innovations to improve the quality of life of those with FI have evolved over the years. Repair of an injured sphincter muscle is still included in the treatment armamentarium. Surgeons can repair a sphincter defect, but long-term results are disappointing [54]. The artificial bowel sphincter, stimulated gracilis wrap, and magnetic sphincter have all had variable success in treating FI, but are no longer available treatments in the United States [55].

Stimulation of the sacral nerves (typically S3) was an accepted treatment of urinary incontinence [56]. The observation that bowel function was improved with this therapy led to trials utilizing sacral neuromodulation (SNM) for FI. Initially, the speculation was that direct stimulation of the muscle occurred with SNM (like a pacemaker for the anal sphincter). While the exact mechanism of action is unknown, direct afferent stimulation to the brain with resultant brain stimulation is felt to be mechanism of action. The beauty of this therapy is that it is done in two stages and allows a trial of stimulation and, if improvement is recorded, the permanent device can be implanted. Additionally, SNM is approved for patients with a sphincter defect of up to 60°, but even patients with a defect up to 120° have reportedly had successful results [57]. Lastly, 35% of SNM patients assessed at 5-year follow-up achieved complete continence, an outcome not matched with other current therapies [25].

SNM has minimal morbidity. Problems with lead erosion or displacement along with the need to replace the battery about every 5 years remain long-term factors that require continuous contact with these patients [38, 58]. New rechargeable batteries are now available. Numerous published studies from many countries have corroborated the optimistic results with SNM since the mid 1990s. SNM is currently the therapy of choice for most patients with FI who fail nonsurgical therapy.

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Hui, V.W., da Silva, G. (2021). Treatment for Fecal Incontinence: Neuromodulation. In: Kobashi, K.C., Wexner, S.D. (eds) Female Pelvic Medicine. Springer, Cham. https://doi.org/10.1007/978-3-030-54839-1_14

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