faecal incontinence in adults - review

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For personal use. Only reproduce with permission from Elsevier Ltd

Review

Faecal incontinence is a surprisingly common disorderthat receives little attention in general and medicalpublications. It can contribute to medical morbidity(such as urinary-tract infections and decubitus ulcers)and can burden patients with substantial, continuousnancial expenses, 1 but its main effect is on quality of life. Patients with faecal incontinence sufferembarrassment, shame, and sometimes depression;some must plan their life around maintaining easy andrapid access to a toilet. Not uncommonly, patientscurtail or even entirely avoid activities that othermembers of society take for granted: shopping, going tothe cinema, dining out, or having sexual intercourse.

Sadly, many of these lifestyle limitations areunnecessary, because most cases of faecal incontinenceare treatable. Barriers to treatment include theunwillingness of patients to broach the subject withhealth-care providers because of embarrassment or lackof knowledge about the availability of treatment. Evenworse, many health-care providers are similarly reticentor ignorant.

EpidemiologyFaecal incontinence is the involuntary loss of rectalcontents through the anal canal. The true prevalence isunknown, owing to the lack of standard denitionsbased on severity and frequency, differences in datacollection, under-reporting of symptoms by patients,and variations in the populations sampled. Internationalpopulation-based studies have provided widely varyingestimates of prevalence, ranging from 0004% to 18%. 26A US telephone survey found a prevalence of 22%; of the people who reported symptoms, 30% were over 65years old and 63% were female. 5 Most reported clinicalseries have a substantial predominance of femalepatients, but epidemiological studies tend to show anequal sex distribution. The reason for this discrepancy isnot known, but it might relate partly to the age and sexof individuals who actively seek treatment.

The prevalence of faecal incontinence strongly

depends on the population studied. In Switzerland,7

theprevalence was 44% in the community, 56% forgeneral outpatients, 67% for antenatal patients, and159% for urogynaecology patients. A US study of

outpatients 2 found an overall prevalence of 184%. Theprevalence was twice as high for patients visiting agastroenterologist (260%) as for those seeing aprimary-care physician (134%). The US data, stratiedby frequency of episodes, showed that incontinenceoccurred daily in 27% of patients, weekly in 45%, andmonthly or less in 71%. Symptomatic faecalincontinence occurs in 21% of women presenting withurinary incontinence, pelvic-organ prolapse, or both. 7

Faecal incontinence disproportionately affectsindividuals with severe physical and mental disabilities.Patients living in institutions have an extremely highrate of faecal incontinence. Poor functional status,

impaired cognitive ability, and limited mobility allcontribute to incontinence in nursing-home residents, 8and the rates of incontinence rise with the length of time spent in nursing homes. 9 A Canadian study of long-term hospital patients found a prevalence of 46%. 10Similarly, in a US survey of patients in nursing homes,47% had faecal incontinence. 3 One explanation for thesestrikingly high proportions is the advanced age, severedebility, and numerous associated medical problems of this population. However, another explanation could bethat faecal incontinence affecting a child or parentsimply cannot be managed by most families and that itsdevelopment generally mandates nursing-homeplacement. Two studies of older patients (one focusedon patients in nursing homes, the other on those livingat home) found an association between severe faecalincontinence and increasing mortality. 9,11

Under-reporting of symptoms by patients is a majorreason for undertreatment. Only a third of symptomaticpatients in the USA discuss their faecal incontinencewith their physicians. 2 In the United Arab Emirates,60% of multiparous women with faecal incontinence donot seek medical advice because of embarrassment, the

Faecal incontinence can affect individuals of all ages and in many cases greatly impairs quality of life, butincontinent patients should not accept their debility as either inevitable or untreatable. Education of the generalpublic and of health-care providers alike is important, because most cases are readily treatable. Many cases of mildincontinence respond to simple medical therapy, whereas patients with more advanced incontinence are best caredfor after complete physiological assessment. Recent advances in therapy have led to promising results, even forpatients with refractory incontinence. Health-care providers must make every effort to communicate fully withincontinent patients and to help restore their self-esteem, eliminate their self-imposed isolation, and allow them toresume an active and productive lifestyle.

Faecal incontinence in adultsRobert D Madoff, Susan C Parker, Madhulika G Varma, Ann C Lowry Lancet2004; 364: 62132

Division of Colon and RectalSurgery, Department of Surgery, University of Minnesota, Minneapolis, MN,USA(R D Madoff MD,S C ParkerMD, A C Lowry MD)and Department of Surgery,University of California, SanFrancisco, CA(M G Varma MD)

Correspondence to:Dr Robert D Madoff, 393 DunlapStreet North, Suite 500, St Paul,

MN 55104, USAmadof001@ umn.edu

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Search strategy and selection criteria

MEDLINE was used to search for articles related to faecalincontinence, emphasising those published from January,1998. The Cochrane Database of Systemic Reviews was alsoqueried for reviews related to faecal incontinence.


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drugs (eg, narcotics, antipsychotics, antidepressants,diuretics, and calcium-channel blockers). 45

Despite the importance of adequate pelvic-oorfunction, maintenance of continence depends on anintact chain of anatomical structures and physiologicalmechanisms, a sequence extending from the anus to thebrain. Patients must have the awareness and desire tomaintain continence. Many patients with dementia areincontinent because of a lack of interest in, or awarenessof, bowel function. Neurological disease or injury thataffects the brain, spinal cord, or peripheral nerves cancause incontinence. Congenital neurological causesinclude spina bida, myelomeningocele, andmeningocele. Acquired neurological causes includestroke, tumours, spinal-cord injury, multiple sclerosis,and diabetic autonomic neuropathy.

Abnormal gastrointestinal function can also causefaecal incontinence. Excessive stool volume and rapidgut transit can overwhelm an entirely normal pelvicoor. Contributory abnormalities include intestinalmalabsorption, inammatory bowel disease, andinfectious diarrhoea.

Finally, we should emphasise that in many casesfaecal incontinence arises from a combination of factors. Pudendal neuropathy commonly accompaniesobstetric sphincter injury, as already noted. Similarly,

women with pre-existing irritable bowel syndrome havemore postpartum defecatory urgency and incontinenceto atus than those without, despite a similar frequencyof sphincter injury. 46 The fact that many women withsphincter injuries do not develop incontinence untillater in life also suggests a cumulative, multifactorialprocess. The possible causes of incontinence aresummarised in the panel.

AssessmentMany patients nd the subject of faecal incontinencedifcult to discuss, so they may provide limited ormisleading information. Common complaints includeurgency, pruritus (which is caused by soiling), anddiarrhoea, a term commonly used by patients todenote incontinence. Clinicians eliciting suchcomplaints should investigate further, particularly if thepatients history (eg, recent vaginal delivery) or physicalndings suggest faecal incontinence. True incontinencemust be differentiated from perineal soiling due toinadequate hygiene or prolapsing haemorrhoids.

HistoryWhen taking the history, clinicians should attend tothese essential elements: the onset and type of incontinence (atus, liquid, or solid stool); the frequencyof episodes; and any related changes in bowel functionor stool consistency. Solid stool is easier to control thanliquid, so the loss of solid stool generally indicates agreater degree of physiological impairment. However,loss of liquid stool is more troublesome to patients than

infrequent loss of solid stool. 47 The degree of incontinence can also be inferred from the patients useof pads or other protection and from restrictive changesin lifestyle, but these behavioural factors may be morestrongly inuenced by the patients anxiety than theactual severity of the disorder. Incontinence can beclassied into two categories on basis of the history:passive (unconscious loss of stool) and urge (inability tocontrol a perceived impending bowel movement). 48

Many patients with physical and psychologicalimpairments have faecal incontinence, so assessment of the patients functional status is important. Physicaldisabilities can impede access to a toilet, precludetransfer to or sitting on a commode, or prevent cleaningup after bowel movements. Cognitive impairment canaffect the ability to sense the need to defecate or thedesire to defecate in a controlled way. Environmentalassessment in some cases uncovers contributory factorsto incontinence, such as a lack of accessible toilets.

Scoring systemsPlanning of treatment and assessment of the resultsrequires a judgment of the severity of incontinence. In


Panel: Causes of incontinence

CongenitalImperforate anusRectal agenesisCloacal defectsMyelomeningoceleMeningocele

AnatomicalObstetric injury, vaginal deliveryAnorectal surgerySphincter-sparing bowel resectionPelvic fractureAnal impalement

NeurologicalDiabetes mellitusMultiple sclerosisStrokeDementiaCentral nervous system tumour, infection, traumaSpina bidaPudendal neuropathy

FunctionalPsychiatric disorderMalabsorption

Inammatory bowel diseaseRadiation proctitisHypersecretory tumoursRectal intussusception, prolapseFaecal impactionPhysical disabilities


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contrast to many other disorders, no physiological indexof faecal incontinence accurately reects clinicalseverity.49 That fact led to the development of scoringsystems based on patients reports of symptoms. 50 Themost widely used system includes as variables thefrequency and type of incontinence, the extent of lifestyle changes, and the need to wear a pad. 51 Althoughnone of the currently used scoring systems has beenpsychometrically validated, the scores with all four

systems compared in one study correlated with thephysicians clinical impression. 50,52

Several issues must be resolved before an ideal scoringsystem is developed: the denition of incontinence mustbe standardised; the optimum method of data collectionmust be decided on (ie, diary versus patients recall); theneed for data beyond type and frequency must beassessed; and the assignment of numerical values to thecombinations of type and frequency must be validated.The developers of the faecal incontinence severity indexused patients input to assign numerical values, butfurther work is necessary. 47,50 Interpretation of publications on incontinence is difcult because of thelack of standardisation, and even more important,because various methods are used for data collection.For example, maintenance of a daily diary of bowelmovements is a far more stringent method thanpatients recall, so results of treatment may appear to beworse. Even the diary approach is limited by theconfounding factor of the patients activity: the mostseverely affected patient can appear continent byrefusing to venture from a nearby toilet.

Quality of life should be assessed independently of severity, because the two measures do not necessarilycorrelate. Overall health-status instruments andgastrointestinal quality-of-life instruments have been

used to measure quality of life related to faecalincontinence, with mixed results. 53,54 A recently validatedincontinence-specic quality-of-life scale measures fourvariables (lifestyle, coping/behaviour, depression/self-perception, and embarrassment); it is more sensitivethan global scales. 55

Physical examinationPhysical examination reveals the cause of theincontinence in many cases. Pertinent ndings includea thinned or deformed perineal body and scars fromprevious surgery or trauma. Breakdown of the perianalskin is a consequence, not a cause of incontinence, butskin condition should be noted and addressed. Gapingof the anus suggests rectal prolapse, which can usuallybe demonstrated with Valsalvas manoeuvre. Digitalrectal examination can be used to diagnose faecalimpaction associated with overow incontinence; suchan examination is essential to exclude tumours in theanal canal or low rectum. Furthermore, the examinercan assess both resting anal-sphincter tone and thepatients ability to augment it with voluntary squeezeeffort. Diminished perianal sensation and the absenceof an anal wink suggest a neurogenic cause of incontinence.

Endoscopy to exclude a mass or inammatorycondition is a key adjunct to the physical examination.Flexible sigmoidoscopy is adequate in most cases, butcomplete colonoscopy should be done if the patient hasunexplained diarrhoea, bleeding, or changed bowelhabits. The patients ability to retain a 100 mL water

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Figure 2:Endoanal ultrasonography

Normal appearance

External sphincter defect

Internal sphincter defect


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enema is a useful bedside measure of sphincterfunction.

Anorectal physiology testingTesting of anorectal physiology is useful both as adiagnostic tool and as a way to quantify the magnitudeof the physiological defect. Such testing is particularlyimportant when the results of the physical examinationare normal, when rectal prolapse is suspected but notdemonstrable, or when surgery is contemplated. Usefullaboratory studies include endoanal ultrasonography,anal manometry, electromyography, and defecography.

ImagingEndoanal ultrasonography is a simple and rapidtechnique that permits accurate delineation of anal-sphincter anatomy (gure 2). When done by anexperienced ultrasonographer, the method hassensitivity and specicity of almost 100% in identifyingdefects of the internal and external sphincter. 56 It canalso reveal unsuspected sphincter injuries in a patientthought to have neurogenic incontinence or rule outsignicant anatomical pathology in a patient withsuspected sphincter disruption; either result might leadto a change in the planned therapy. 57 Sphincterabnormalities are shown on endoanal ultrasonography

in up to 90% of women whose sole risk factor for faecalincontinence is obstetric trauma; thus, this imagingtechnique is essential for complete assessment of incontinent parous women.

MRI is another approach to pelvic-oor imaging(gure 3). 58 The need for an endoanal coil to optimiseimaging remains controversial. Advantages of MRIinclude lower dependency on the operator, a wider eldof view, and the ability to undertake dynamic studies of pelvic-oor function. Endoanal ultrasonography andMRI have similar accuracy in diagnosing defects of theexternal anal sphincter, but endoanal ultrasonography ismore accurate in diagnosing injuries of the internal analsphincter. 59

Manometry Anal manometry assesses function of the internal andexternal anal sphincter, the rectoanal inhibitory reex,and rectal sensation. It uses a microballoon, a water-perfused catheter, or a solid-state transducer. In arelaxed patient, resting pressures mainly reect functionof the internal anal sphincter; squeeze pressuresrepresent voluntary contraction of the external analsphincter. Normal values of both resting and squeezepressures vary among patients: they are lower in womenthan men and in older patients of both sexes. 17 Despite ageneral relation between sphincter pressure andcontinence, sphincter pressure varies substantially inboth continent and incontinent populations. 17,49 That facthelps emphasise the multifactorial nature of incontinence. Furthermore, successful treatment of

incontinent patients will not necessarily correctmanometric abnormalities, and in fact it commonlydoes not.

The rectoanal inhibitory reex causes relaxation of theinternal anal sphincter in response to rectal distension.It is demonstrated by a drop in resting anal pressure inresponse to ination of a rectal balloon. This reex could


Figure 3:MRI of the normal pelvisSagittal phased-array images of the anal canal and perianal structures.AC=anococcygeal body; BS=bulbospongiosus; EAS=external anal sphincter;PB=perineal body; PU=pubic bone. Reprinted with permission.58


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permit sampling of the rectal contents by thetransitional-zone receptors, a process that assists in thedecision to initiate or defer defecation. The exactmechanism of the decision process remains uncertain.This reex is absent in patients with Hirschsprungsand Chagas diseases; its loss after low rectalanastomosis is associated with poor functionaloutcome. 60

Rectal sensory testing includes volumetricmeasurements of the rst detectable sensation, thesensation of fullness, and the maximum toleratedvolume by balloon distension. Hypersensitivity can beseen with inammatory disorders, after irradiation, andwith irritable bowel syndrome; 61 it can lead to urgeincontinence. Blunted sensation can also contribute toincontinence; 62,63 it is associated with megarectum andwith neurogenic disorders such as diabetes and multiplesclerosis. 64,65

Neurophysiological testsNeurophysiological assessment of incontinent patientsis done by single-bre electromyography or pudendal-nerve terminal motor latency (PNTML) testing. Single-bre electromyography shows multiphasic actionpotentials in the external anal sphincter, a ndingdiagnostic of muscle denervation and subsequentreinnervation. 41 Although it provides more directevidence of denervation, single-bre electromyographyhas largely been supplanted in many centres by PNTMLtesting, which uses a glove-mounted intra-anal electroderather than a needle electrode. 66 PNTML testingmeasures conduction time from stimulation of thenerve at the ischial spine to contraction of the externalanal sphincter. Because PNTML testing measuresconduction time in the fastest remaining nerve bres,signicant nerve damage is sometimes overlooked.Results are also inuenced by the patients body typeand the technicians expertise. 67 Long latencies areassociated with traction injury to the nerve as well aswith primary neuropathies. Pudendal neuropathy isseen in up to 70% of patients with faecal incontinence,and in more than 50% of patients with sphincterinjury. 68 Some investigators have related the presence of pudendal neuropathy to poor results aftersphincteroplasty, 69 but others have not been able to

demonstrate an association.70

Enthusiasm for PNTMLtesting has been tempered by the lack of consensusabout its accuracy and predictive value for outcome aftersurgery.

Defecography Defecography examines rectal emptying of a soft bariumpaste under uoroscopy. Although useful forassessment of patients with obstructed defecation, it haslimited value in most incontinent patients. Its main rolein patients with faecal incontinence is to help diagnoseoccult rectal prolapse or other suspected pelvic-oorabnormalities (such as a poorly emptying rectocele).

TreatmentMedical therapyAn algorithm for the treatment of incontinence is givenin gure 4. Initial treatment should be conservative.Dietary changes (eg, avoidance of foods that causediarrhoea or urgency), the addition of supplementarybre, and bowel habit training are useful for mostpatients. They may even be the only treatment necessaryfor those with mild incontinence. Barrier creams, cottonwicks at the anus, and rectal washouts can prevent orameliorate anal excoriation secondary to leakage. Inpatients with diarrhoea, assessment of the cause andspecic treatment directed at the underlying cause areneeded. Patients with idiopathic diarrhoea are treatedwith antidiarrhoeal medications, such as loperamide,diphenoxylate, and bile-acid binders. Loperamidedecreases intestinal motility and secretion and increases


Figure 4:Algorithm for incontinence

Faecal incontinence

Assess/treat aetiology of diarrhoea: colitis, hypersecretorytumour, radiation, overflow

Medical treatment: fibre, dietary, barrier cream, antidiarrhoealagents, bowel regimen

Diarrhoea?

Anorectal physiology testing Anorectal manometry Pudendal nerve testing Endoanal ultrasonography Defecography (optional)

Yes

Yes

Yes

Yes

Improves

Improves

Sphincter defect?

Major defect?

Overlappingsphincteroplasty

Endoanal ultrasonography:persistent sphincter defect?

Repeat sphincteroplasty withor without biofeedback

Biofeedback

Does notresolve

No

No

No

Fails

Stoma

Consider indications,age, comorbidities,technical issues

Dynamic graciloplastyArtifical sphincterSacral stimulation

No

History and physicalexamination

Improves

Improves Fails

Fails


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sphincter pressure. 71 Bulking agents, such as psylliumcompounds, are also used, because control of solid stoolis easier than control of liquid stool. Conversely, patientswith constipation and faecal impaction may needroutine enemas or laxatives to empty the rectum, so thatoverow incontinence does not occur. Incontinentpatients with associated irritable bowel syndromepresent a therapeutic challenge, given their alternatingsymptoms of diarrhoea and constipation.

Novel approaches to the medical treatment of incontinence include oestrogen replacement therapy inpostmenopausal women, 72 amitriptyline, 73 and valproatesodium. 74 Topical 10% phenylephrine increased restinganal pressure in healthy volunteers 75 and improvedseepage in patients with ileoanal reservoirs, 76 but it wasineffective in a randomised controlled trial of incontinent patients. 77

BiofeedbackBiofeedback is commonly the rst treatmentrecommended if medical therapy fails. It is appealingbecause it is simple, cheap, and without adverse physicaleffects. The goal is improved contraction of the externalanal sphincter in response to rectal distention. Variousprotocols and feedback equipment have beenreported. 7886 In general, three different protocols are

used: coordination training, which teaches patients tocontract the sphincter muscle in response to rectaldistension; sensory training, which teaches patients torecognise progressively smaller volumes of rectaldistension; and strength training, which teachespatients to isolate and exercise the sphincter musclewithout using rectal distension. The length and thenumber of sessions recommended vary widely. In mostcentres, manometry equipment or an electromyographicrectal probe is used to provide information to patients.The technique chosen does not seem to affect thelikelihood of success. 87

Success rates after biofeedback range from 38% to100%.64,78,8890 The presence of a sphincter defect limitsbut does not preclude the possibility of a goodresponse. 90 Pudendal neuropathy does not adverselyaffect clinical outcome, 91,92 though poor results have beenreported in patients with severe neurogenic faecalincontinence who lack rectal sensation. 93 The reportedsuccess rates for coordination training and for strengthtraining do not differ signicantly.

Interpretation of reports on biofeedback is difcult.Most studies have been retrospective. Parallel designand randomisation have rarely been used. The denitionof success varies widely, and follow-up is short. In moststudies, the sample size is small and criteria forselection of patients are not reported. Few studiesinclude controls. 78,94 Studies comparing biofeedback withattentive medical care alone are rare and have givenconicting results. 88,95 However, a randomised controlledtrial showed no advantage of biofeedback over standard

medical and nursing care (advice) or advice plussphincter exercises. 96

Many issues about biofeedback remain unresolved. Itis not uniformly available and not covered by all healthinsurance schemes. No clear criteria for selection of patients have been identied. The optimum protocol,equipment, and duration of treatment are unknown.The mechanism of improvement is poorly understood.No consistent change in sphincter pressures, rectalsensation, or duration of contraction has been reported.Long-term follow-up data are limited, albeit promising,in a few small studies. 9799

SurgeryTo restore the anal aperture by repairing sphincterdefects is the cornerstone of surgery for incontinence.At the time of a recognised obstetric injury, immediatedirect repair is advocated, yet persistent defects arecommon. 29,35,100 If immediate repair is not attempted,patients should wait at least 3 months before surgery, sothat the magnitude of the functional decit can bedened, physiological assessment can be done, and localtissue inammation and oedema can resolve.

Sphincteroplasty Established injuries in symptomatic patients are treated

by overlapping sphincteroplasty. In this technique, acurvilinear incision is made over the perineal body, andthe scarred sphincter remnant is dissected back tohealthy muscle on either side. The scar is transected, butnot excised, and is used as part of the overlapping repairto restore an intact ring of muscle. Many surgeonsplicate the levator muscles anteriorly, in an effort to addlength to the restored anal canal, but no objective datasupport this approach. Other surgeons avoid levator-muscle plication out of fear of causing dyspareunia.Individual repair of the internal and external analsphincter has been advocated by some researchers, but itis not widely practised; moreover, proof of its superiorityto single-layer repair is lacking. 101 Routine sphinctero-plasty is generally done without creation of a divertingstoma; randomised trials have shown no benet fromdiversion and morbidity was increased. 102,103

As with all therapies for incontinence, the reportedsuccess of sphincteroplasty depends on the denitionsof incontinence and on the data-collection method. Still,most series report that 6088% of patients achieve anexcellent or good outcome, dened as perfect continenceor as incontinence to atus with minor staining. 69,70,104106About 1520% experience no change or a worseoutcome. However, several studies have shown that theresults of sphincteroplasty deteriorate substantially withtime. 105,107109

Some 69,106,109,110 but not all series 69,103,108 suggest that thepresence of pudendal neuropathy adversely affects theoutcome of overlapping sphincter repair. Patients forwhom sphincteroplasty fails should undergo follow-up



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ultrasonography to ensure that the muscle wrap isintact; patients with persisting defects can undergorepeat repair after 612 months. 111,112 Biofeedback can beeffective salvage therapy for patients with suboptimumresults after sphincteroplasty. 91

DiversionIf all other therapies have failed or if comorbiditiespreclude more aggressive therapy, faecal diversionremains an excellent alternative. Many patients expressreluctance to live with a stoma, but counselling by thephysician and an enterostomal therapist can bepersuasive. Colostomy admittedly does not confercontinence, but it does restore control of bowelevacuation and permits resumption of a normalpersonal and social life. Emphasis should be placed oncreating a well-constructed stoma at an appropriate site,to limit difculty with its management.

InnovationsRestoration of continence to patients when traditionaltreatment fails, or when traumatic or neurogenicinjuries are extensive, remains a challenge. Even afteran initial successful result with biofeedback or anteriorsphincteroplasty, only about 50% of patients retain thepost-treatment degree of continence for 3 years or

longer.97,106,108

Options available to such patients includedynamic graciloplasty, an articial anal sphincter, andsacral-nerve stimulation.

Dynamic graciloplasty and articial anal sphinctersare advanced variations of anal encirclement. Theearliest and simplest version of anal encirclement wasthe use of silver wire, described by Thiersch in 1891.Later, Pickrell and colleagues described analencirclement by use of the gracilis muscle, and otherresearchers have favoured use of gluteal-muscle aps. 113Functional results with passive muscle wraps arelimited by the inability of patients to maintain, at alltimes, continuous voluntary contraction of the muscle.Dynamic graciloplasty combines transposition of thegracilis muscle with electrical stimulation via animplantable pulse generator. Application of gradedelectrical stimulation allows conversion of the fast-twitch, fatiguable gracilis muscle to a slow-twitch,fatigue-resistant muscle that more closely resembles theanal sphincter. 114

Baeten and co-workers rst reported the use of electrical stimulation with a gracilis-muscle wrap forfaecal incontinence in 1988 115 and subsequentlyreported a 72% continence rate. However, multicentrestudies have been unable to replicate this degree of success without substantial morbidity and highreoperation rates. 116,117 This discrepancy appears to ariseat least partly from a relative lack of experience with thetechnique. Surgeons new to the operation have highermorbidity rates and lower success rates than those withsubstantial experience. 116 Dynamic graciloplasty

remains an option for refractory incontinence in alimited number of centres, but it is not approved for usein the USA.

The articial anal sphincter (Acticon Neosphincter,American Medical Systems, Minneapolis, MN, USA)maintains continence via a uid-lled cuff thatsurrounds and compresses the anal canal. The patientcontrols the device via a pump placed in the scrotum orlabia majora. Squeezing the pump nine to 12 timesforces the uid from the cuff into a reservoir balloon,which is implanted behind the pubic bone inpreperitoneal tissues. Once the cuff is deated, the analcanal is open, allowing the passage of stool. The cuff then gradually reinates to occlude the anal canal untildefecation is again desired.

Christiansen and Lorentzen rst reportedimplantation of an articial anal sphincter for faecalincontinence in 1987. 118 Since then, variable results withthe technique have been reported. 119124 Lehur andcolleagues reported successful results in 75% of patients, with 29% requiring at least temporary removalof the device.123 By contrast, Malouf and co-workersreported successful results in only 38% of patients;infection, particularly with meticillin-resistantStaphylococcus aureus,was the major cause of failure. 124In a multicentre clinical trial, 67% of patients had a

functional device in place at 1 year postoperatively .125

The mean incontinence score (range 0120) droppedfrom 105 (incontinent to liquids and solids daily) to 48(seepage). The infection rate necessitating surgicalrevision was 25%. In all, 46% of patients (51 of 112)required surgical revision; 37% (41 of 112) requireddevice removal, seven of whom (17%) underwentsuccessful reimplantation.

The articial anal sphincter is suitable for many of thesame patients who are candidates for dynamicgraciloplasty. However, the perineal soft tissue must besufcient to allow placement of a Silastic cuff aroundthe anal canal. The device is now available in Europe,Canada, and the USA.

Sacral-nerve stimulation, like the articial analsphincter, was initially devised for urinary incontinence.Matzel and colleagues introduced the use of suchstimulation in 1995 to treat patients with functional, butnot anatomical, decits of the anal sphincter muscle. 126The procedure entails placing an electrode in a sacralforamen (generally S3) to stimulate the sacral nerves.The desired effect is maximum contraction of pelvicmuscles, with the minimum possible stimulation of thebres to the leg. Once the optimum site has beenselected, the lead is connected to a temporary externalpulse generator for 2 weeks of test stimulation. If function improves adequately, a permanent pulsegenerator is implanted. Both the initial operation forlead placement and the subsequent one for placement of the pulse generator are done under local anaesthesiawith conscious sedation.



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Recent series of patients treated by sacral-nervestimulation have shown promising results with littlemorbidity. 127,128 Success rates after short-term stimulationapproach 90%. 129 The great majority of patients for whomtest stimulation is successful remain continent afterpermanent implantation. 127,130132 However, infection andlead displacement remain challenging in up to 25% of patients. 133 Because of continuing pain, device reposi-tioning or explantation has been needed for severalpatients. 127,130

Most studies of sacral-nerve stimulation have shownimprovement in both resting and squeeze analpressures as well as increased rectal sensation. 133

Ambulatory manometry has shown reduced rectalcontractility and suppression of spontaneous analrelaxation. 129 The mechanism by which these effects aremediated remains uncertain, though many researchersbelieve that sacral-nerve stimulation works bymodulating local reex arcs. The mechanism could wellbe multifactorial. Sacral-nerve stimulation is available inEurope; in the USA, qualifying patients with faecalincontinence can enrol in a trial approved by the Foodand Drug Administration.

Recent work has investigated novel minimally invasiveapproaches to faecal incontinence. One option, theaddition of a bulking agent to the anal canal to augment

resting tone, stems from the routine use of bulkingagents for treatment of urinary incontinence caused byintrinsic urinary-sphincter deciency. The successfuluse of implantable microballoons, 134 carbon-coatedbeads, 135 autologous fat, 136 silicone,137 and collagen 138 haveeach been reported in small series with low morbidities.However, both the magnitude and the durability of improvement have varied with such techniques. 139 Asecond investigational approach has used radio-frequency energy to apply a series of small submucosalburns to the anal canal. A pilot series showed promisingresults, 140 but a larger trial showed a lesser degree of improvement. 141

ConclusionFaecal incontinence is an embarrassing and sometimesdebilitating disorder. Although incontinence is generallytreatable, many patients remain untreated because theydo not report their symptoms or because their health-care provider is not familiar with available treatmentoptions. Conservative therapy is successful for manycases of mild incontinence, but more severe casesshould be formally assessed before treatment isundertaken. Recent advances have provided newtherapeutic options for patients with refractoryincontinence.Conict of interest statementRobert D Madoff consults for Medtronic, manufacturer of the hardwareused for dynamic graciloplasty and sacral-nerve stimulation, and forSolvay Pharmaceuticals, manufacturer of topical phenylephrinehydrochloride. Susan C Parker consults for Medtronic and for American


Medical Systems, manufacturer of the Acticon Neosphincter articialbowel sphincter. None of the authors received payment (except fromThe Lancet) for writing this review.

AcknowledgmentsWe thank Alexandra A Broek for assistance in preparation of the review,and Mary E Knatterud for editorial help.

References1 Mellgren A, Jensen LL, Zetterstrom JP, Wong WD, Hofmeister JH,

Lowry AC. Long-term cost of fecal incontinence secondary toobstetric injuries. Dis Colon Rectum1999; 42: 85765.

2 Johanson JF, Lafferty J. Epidemiology of fecal incontinence: thesilent afiction. Am J Gastroenterol1996; 91: 3336.

3 Nelson R, Furner S, Jesudason V. Fecal incontinence in Wisconsinnursing homes: prevalence and associations. Dis Colon Rectum1998; 41: 122629.

4 Thomas TM, Egan M, Walgrove A, Meade TW. The prevalenceof faecal and double incontinence. Community Med 1984; 6:21620.

5 Nelson R, Norton N, Cautley E, Furner S. Community-basedprevalence of anal incontinence. JAMA1995; 274: 55961.

6 Drossman DA, Li Z, Andruzzi E, et al. US householder survey of functional gastrointestinal disorders: prevalence, sociodemography,and health impact. Dig Dis Sci1993; 38: 156980.

7 Faltin DL, Sangalli MR, Curtin F, Morabia A, Weil A. Prevalence of anal incontinence and other anorectal symptoms in women.Int Urogynecol J Pelvic Floor Dysfunct2001; 12: 11720.

8 Porell F, Caro FG, Silva A, Monane M. A longitudinal analysis of nursing home outcomes. Health Serv Res1998; 33: 83565.

9 Chassagne P, Landrin I, Neveu C, et al. Fecal incontinence in theinstitutionalized elderly: incidence, risk factors, and prognosis.Am J Med1999; 106: 18590.

10 Borrie MJ, Davidson HA. Incontinence in institutions: costs andcontributing factors. CMAJ 1992; 147: 32228.

11 Nakanishi N, Tatara K, Shinsho F, et al. Mortality in relation tourinary and faecal incontinence in elderly people living at home.Age Ageing 1999; 28: 30106.

12 Rizk DE, Hassan MY, Shaheen H, Cherian JV, Micallef R, Dunn E.The prevalence and determinants of health care-seeking behaviorfor fecal incontinence in multiparous United Arab Emiratesfemales. Dis Colon Rectum2001; 44: 185056.

13 Jorge JM. Anorectal anatomy and physiology. In: Wexner SD, ed.Fundamentals of anorectal surgery, 2nd edn. Philadelphia:W B Saunders, 1998: 124.

14 Lestar B, Penninckx F, Kerremans R. The composition of anal basalpressure: an in vivo and in vitro study in man. Int J Colorectal Dis1989; 4: 11822.

15 Johnson MA, Polgar J, Weightman D, Appleton D. Data on thedistribution of bre types in thirty-six human muscles: an autopsystudy. J Neurol Sci1973; 18: 11129.

16 Gibbons CP, Trowbridge EA, Bannister JJ, Read NW. Role of analcushions in maintaining continence. Lancet1986; 1: 88688.

17 McHugh SM, Diamant NE. Effect of age, gender, and parity on analcanal pressures: contribution of impaired anal sphincter function tofecal incontinence. Dig Dis Sci1987; 32: 72636.

18 Matzel KE, Schmidt RA, Tanagho EA. Neuroanatomy of the striatedmuscular anal continence mechanism: implications for the use of neurostimulation. Dis Colon Rectum1990; 33: 66673.

19 Snooks SJ, Swash M. The innervation of the muscles of continence.Ann R Coll Surg Engl1986; 68: 4549.

20 Parks AG. Anorectal incontinence. Proc R Soc Med1975; 68:68190.

21 Duthie HL, Gairns FN. Sensory nerve endings and sensation in theanal region of man. Br J Surg 1960; 47: 58595.

22 Garcia-Aguilar J, Belmonte C, Wong WD, Lowry AC, Madoff RD.Open vs closed sphincterotomy for chronic anal ssure: long-termresults. Dis Colon Rectum1996; 39: 44043.

23 Nyam DC, Pemberton JH. Long-term results of lateral internalsphincterotomy for chronic anal ssure with particular reference toincidence of fecal incontinence. Dis Colon Rectum1999; 42:130610.

24 MacIntyre IM, Balfour TW. Results of the Lord non-operativetreatment for haemorrhoids. Lancet1972; 1: 109495.


10/12


Review

25 Read MG, Read NW, Haynes WG, Donnelly TC, Johnson AG. Aprospective study of the effect of haemorrhoidectomy on sphincterfunction and faecal continence. Br J Surg 1982; 69: 39698.

26 Otto IC, Ito K, Ye C, et al. Causes of rectal incontinence aftersphincter-preserving operations for rectal cancer. Dis Colon Rectum1996; 39: 142327.

27 Ho YH, Tsang C, Tang CL, Nyam D, Eu KW, Seow-Choen F.Anal sphincter injuries from stapling instruments introducedtransanally: randomized, controlled study with endoanal ultrasoundand anorectal manometry. Dis Colon Rectum2000; 43: 16973.

28 Vaizey CJ, Kamm MA, Bartram CI. Primary degeneration of theinternal anal sphincter as a cause of passive faecal incontinence.Lancet1997; 349: 61215.

29 Warshaw JS. Obstetric anal sphincter injury: incidence, risk factors,and repair. Sem Colon Rectal Surg 2001; 12: 9097.

30 Sultan AH, Kamm MA, Hudson CN, Thomas JM, Bartram CI.Anal-sphincter disruption during vaginal delivery. N Engl J Med1993; 329: 190511.

31 Faltin DL, Boulvain M, Irion O, Bretones S, Stan C, Weil A.Diagnosis of anal sphincter tears by postpartum endosonography topredict fecal incontinence. Obstet Gynecol2000; 95: 64347.

32 Varma A, Gunn J, Gardiner A, Lindow SW, Duthie GS. Obstetricanal sphincter injury: prospective evaluation of incidence.Dis Colon Rectum1999; 42: 153743.

33 Zetterstrom J, Mellgren A, Jensen LL, et al. Effect of delivery onanal sphincter morphology and function. Dis Colon Rectum1999;42: 125360.

34 Oberwalder M, Connor J, Wexner SD. Meta-analysis to determinethe incidence of obstetric anal sphincter damage. Br J Surg 2003; 90:133337.

35 Varma A, Gunn J, Lindow SW, Duthie GS. Do routinely measureddelivery variables predict anal sphincter outcome? Dis Colon Rectum1999; 42: 126164.

36 Sultan AH, Kamm MA, Hudson CN, Bartram CI. Third degree

obstetric anal sphincter tears: risk factors and outcome of primaryrepair. BMJ 1994; 308: 88791.37 Faltin DL, Sangalli MR, Roche B, Floris L, Boulvain M, Weil A.

Does a second delivery increase the risk of anal incontinence?Br J Obstet Gynecol2001; 108: 68488.

38 MacArthur C, Glazener CM, Wilson PD, et al. Obstetricpractice and faecal incontinence three months after delivery.Br J Obstet Gynecol2001; 108: 67883.

39 Sorensen M, Tetzschner T, Rasmussen OO, Bjarnesen J,Christiansen J. Sphincter rupture in child birth. Br J Surg 1993; 80:39294.

40 Snooks SJ, Swash M, Setchell M, Henry MM. Injury to innervationof pelvic oor sphincter musculature. Lancet1984; 2: 54650.

41 Neill ME, Swash M. Increased motor unit bre density in theexternal anal sphincter muscle in ano-rectal incontinence: a singlebre EMG study. J Neurol Neurosurg Psychiatry1980; 43: 34347.

42 Parks AG, Swash M, Urich H. Sphincter denervation in anorectalincontinence and rectal prolapse. Gut 1977; 18: 65665.

43 Snooks SJ, Barnes PR, Swash M, Henry MM. Damage to theinnervation of the pelvic oor musculature in chronic constipation.Gastroenterology1985; 89: 97781.

44 Kiff ES, Barnes PR, Swash M. Evidence of pudendal neuropathy inpatients with perineal descent and chronic straining at stool. Gut1984; 25: 127982.

45 Wrenn K. Fecal impaction. N Engl J Med1989; 321: 65862.46 Donnelly VS, OHerlihy C, Campbell DM, OConnell PR.

Postpartum fecal incontinence is more common in women withirritable bowel syndrome. Dis Colon Rectum1998; 41: 58689.

47 Rockwood TH, Church JM, Fleshman JW, et al. Patient andsurgeon ranking of the severity of symptoms associated with fecalincontinence: the fecal incontinence severity index. Dis ColonRectum 1999; 42: 152532.

48 Engel AF, Kamm MA, Bartram CI, Nicholls RJ. Relationship of symptoms in faecal incontinence to specic sphincterabnormalities. Int J Colorectal Dis1995; 10: 15255.

49 Felt-Bersma RJ, Klinkenberg-Knol EC, Meuwissen SG. Anorectalfunction investigations in incontinent and continent patients:differences and discriminatory value. Dis Colon Rectum1990; 33:47985.

50 Baxter NN, Rothenberger DA, Lowry AC. Measuring fecalincontinence. Dis Colon Rectum2003; 46: 1591605.

51 Jorge JM, Wexner SD. Etiology and management of fecalincontinence. Dis Colon Rectum1993; 36: 7797.

52 Vaizey CJ, Carapeti E, Cahill JA, Kamm MA. Prospectivecomparison of faecal incontinence grading systems. Gut 1999; 44:7780.

53 Eypasch E, Williams JI, Wood-Dauphinee S, et al. Gastrointestinalquality of life index: development, validation and application of anew instrument. Br J Surg 1995; 82: 21622.

54 Sailer M, Bussen D, Debus ES, Fuchs KH, Thiede A. Quality of lifein patients with benign anorectal disorders. Br J Surg 1998; 85:171619.

55 Rockwood TH, Church JM, Fleshman JW, et al. Fecal incontinencequality of life scale: quality of life instrument for patients with fecalincontinence. Dis Colon Rectum2000; 43: 916.

56 Sultan AH, Kamm MA, Talbot IC, Nicholls RJ, Bartram CI. Analendosonography for identifying external sphincter defectsconrmed histologically. Br J Surg 1994; 81: 46365.

57 Liberman H, Faria J, Ternent CA, Blatchford GJ, Christensen MA,Thorson AG. A prospective evaluation of the value of anorectalphysiology in the management of fecal incontinence. Dis ColonRectum2001; 44: 156774.

58 Morren GL, Beets-Tan RG, van Engelshoven JM. Anatomy of theanal canal and perianal structures as dened by phased-arraymagnetic resonance imaging. Br J Surg 2001; 88: 150612.

59 Malouf AJ, Williams AB, Halligan S, Bartram CI, Dhillon S,Kamm MA. Prospective assessment of accuracy of endoanal MRimaging and endosonography in patients with fecal incontinence.AJR Am J Roentgenol2000; 175: 74145.

60 Lewis WG, Martin IG, Williamson ME, et al. Why do somepatients experience poor functional results after anteriorresection of the rectum for carcinoma? Dis Colon Rectum1995;38: 25963.

61 Prior A, Maxton DG, Whorwell PJ. Anorectal manometry inirritable bowel syndrome: differences between diarrhoea andconstipation predominant subjects. Gut 1990; 31: 45862.

62 Buser WD, Miner PB Jr. Delayed rectal sensation with fecalincontinence: successful treatment using anorectal manometry.Gastroenterology1986; 91: 118691.

63 Gladman MA, Scott SM, Chan CL, Williams NS, Luniss PJ. Rectalhyposensitivity: prevalence and clinical impact in patients withintractable constipation and fecal incontinence. Dis Colon Rectum2003; 46: 23846.

64 Wald A, Tunuguntla AK. Anorectal sensorimotor dysfunction infecal incontinence and diabetes mellitus: modication withbiofeedback therapy. N Engl J Med1984; 310: 128287.

65 Caruana BJ, Wald A, Hinds JP, Eidelman BH. Anorectal sensoryand motor function in neurogenic fecal incontinence: comparisonbetween multiple sclerosis and diabetes mellitus. Gastroenterology1991; 100: 46570.

66 Kiff ES, Swash M. Slowed conduction in the pudendal nerves inidiopathic (neurogenic) faecal incontinence. Br J Surg 1984; 71:61416.

67 Yip B, Barrett RC, Coller JA, et al. Pudendal nerve terminal motorlatency testing: assessing the educational learning curve: can weteach our own? Dis Colon Rectum2002; 45: 18487.

68 Roig JV, Villoslada C, Lledo S, et al. Prevalence of pudendalneuropathy in fecal incontinence: results of a prospective study. DisColon Rectum1995; 38: 95258.

69 Gilliland R, Altomare DF, Moreira H Jr, Oliveira L, Gilliland JE,Wexner SD. Pudendal neuropathy is predictive of failure followinganterior overlapping sphincteroplasty. Dis Colon Rectum1998; 41:151622.

70 Buie WD, Lowry AC, Rothenberger DA, Madoff RD. Clinical ratherthan laboratory assessment predicts continence after anteriorsphincteroplasty. Dis Colon Rectum2001; 44: 125560.

71 Hallgren T, Fasth S, Delbro DS, Nordgren S, Oresland T, Hulten L.Loperamide improves anal sphincter function and continence afterrestorative proctocolectomy. Dig Dis Sci1994; 39: 261218.

72 Donnelly V, OConnell PR, OHerlihy C. The inuence of oestrogenreplacement on faecal incontinence in postmenopausal women.Br J Obstet Gynaecol1997; 104: 31115.



11/12


Review

73 Santoro GA, Eitan BZ, Pryde A, Bartolo DC. Open study of low-doseamitriptyline in the treatment of patients with idiopathic fecalincontinence. Dis Colon Rectum2000; 43: 167681.

74 Kusunoki M, Shoji Y, Ikeuchi H, Yamagata K, Yamamura T,Utsunomiya J. Usefulness of valproate sodium for treatmentof incontinence after ileoanal anastomosis. Surgery1990; 107:31115.

75 Carapeti EA, Kamm MA, Evans BK, Phillips RK. Topicalphenylephrine increases anal sphincter resting pressure. Br J Surg 1999; 86: 26770.

76 Carapeti EA, Kamm MA, Nicholls RJ, Phillips RK. Randomized,controlled trial of topical phenylephrine for fecal incontinence inpatients after ileoanal pouch construction. Dis Colon Rectum2000;43: 105963.

77 Carapeti EA, Kamm MA, Phillips RK. Randomized controlled trialof topical phenylephrine in the treatment of faecal incontinence.Br J Surg 2000; 87: 3842.

78 Heymen S, Jones KR, Ringel Y, Scarlett Y, Whitehead WE.Biofeedback treatment of fecal incontinence: a critical review.Dis Colon Rectum2001; 44: 72836.

79 Wald A. Biofeedback therapy for fecal incontinence. Ann Intern Med1981; 95: 14649.

80 Engel BT, Nikoomanesh P, Schuster MM. Operant conditioning of rectosphincteric responses in the treatment of fecal incontinence.N Engl J Med1974; 290: 64649.

81 Norton C, Kamm MA. Anal sphincter biofeedback and pelvic oorexercises for faecal incontinence in adults: a systematic review.Aliment Pharmacol Ther 2001; 15: 114754.

82 Fynes MM, Marshall K, Cassidy M, et al. A prospective, randomizedstudy comparing the effect of augmented biofeedback with sensorybiofeedback alone on fecal incontinence after obstetric trauma.Dis Colon Rectum1999; 42: 75358.

83 Goldenberg DA, Hodges K, Hershe T, Jinich H. Biofeedbacktherapy for fecal incontinence. Am J Gastroenterol1980; 74:34245.

84 Latimer PR, Campbell D, Kasperski J. A components analysis of biofeedback in the treatment of fecal incontinence.Biofeedback Self Regul1984; 9: 31124.

85 Miner PB, Donnelly TC, Read NW. Investigation of mode of actionof biofeedback in treatment of fecal incontinence. Dig Dis Sci1990;35: 129198.

86 Constantinides CG, Cywes S. Fecal incontinence: a simplepneumatic device for home biofeedback training. J Pediatr Surg 1983; 18: 27677.

87 Solomon MJ, Pager CK, Rex J, Roberts R, Manning J. Randomized,controlled trial of biofeedback with anal manometry, transanalultrasound, or pelvic oor retraining with digital guidance alone inthe treatment of mild to moderate fecal incontinence. Dis ColonRectum 2003; 46: 70310.

88 Whitehead WE, Burgio KL, Engel BT. Biofeedback treatment of fecal incontinence in geriatric patients. J Am Geriatr Soc 1985; 33:32024.

89 McHugh S, Walma K, Diamant NE. Fecal incontinence: acontrolled trial of biofeedback. Gastroenterology1986; 90: 15455.

90 Norton C, Kamm MA. Outcome of biofeedback for faecalincontinence. Br J Surg 1999; 86: 115963.

91 Jensen LL, Lowry AC. Biofeedback improves functional outcomeafter sphincteroplasty. Dis Colon Rectum1997; 40: 197200.

92 Rieger NA, Wattchow DA, Sarre RG, et al. Prospective trial of pelvicoor retraining in patients with fecal incontinence. Dis ColonRectum 1997; 40: 82126.

93 van Tets WF, Kuijpers JH, Bleijenberg G. Biofeedback treatment isineffective in neurogenic fecal incontinence. Dis Colon Rectum1996; 39: 99294.

94 Norton C, Hosker G, Brazzelli M. Biofeedback and/or sphincterexercises for the treatment of faecal incontinence in adults.Cochrane Database Syst Rev 2000: CD002111.

95 Loening-Baucke V. Efcacy of biofeedback training in improvingfaecal incontinence and anorectal physiologic function. Gut 1990;31: 1395402.

96 Norton C, Chelvanayagam S, Wilson-Barnett J, Redfern S,Kamm MA. Randomized controlled trial of biofeedback for fecalincontinence. Gastroenterology2003; 125: 132029.

97 Ryn AK, Morren GL, Hallbook O, Sjodahl R. Long-term results of electromyographic biofeedback training for fecal incontinence.Dis Colon Rectum2000; 43: 126266.

98 Enck P, Daublin G, Lubke HJ, Strohmeyer G. Long-term efcacy of biofeedback training for fecal incontinence. Dis Colon Rectum1994;37: 9971001.

99 Guillemot F, Bouche B, Gower-Rousseau C, et al. Biofeedback forthe treatment of fecal incontinence. Dis Colon Rectum1995; 38:39397.

100 Nielsen MB, Hauge C, Rasmussen OO, Pedersen JF, ChristiansenJ. Anal endosonographic ndings in the follow-up of primarilysutured sphincteric ruptures. Br J Surg 1992; 79: 10406.

101 Wexner SD, Marchetti F, Jagelman DG. The role of sphincteroplasty for fecal incontinence reevaluated: a prospectivephysiologic and functional review. Dis Colon Rectum1991; 34:2230.

102 Hasegawa H, Yoshioka K, Keighley MR. Randomized trial of fecal diversion for sphincter repair. Dis Colon Rectum2000; 43:96164.

103 Young CJ, Mathur MN, Eyers AA, Solomon MJ. Successfuloverlapping anal sphincter repair: relationship to patient age,neuropathy, and colostomy formation. Dis Colon Rectum1998;41: 34449.

104 Engel AF, Kamm MA, Sultan AH, Bartram CI, Nicholls RJ.Anterior anal sphincter repair in patients with obstetric trauma.BrJ Surg 1994; 81: 123134.

105 Karoui S, Leroi AM, Koning E, Menard JF, Michot F, Denis P.Results of sphincteroplasty in 86 patients with anal incontinence.Dis Colon Rectum2000; 43: 81320.

106 Londono-Schimmer EE, Garcia-Duperly R, Nicholls RJ, Ritchie JK,Hawley PR, Thomson JP. Overlapping anal sphincter repair forfaecal incontinence due to sphincter trauma: ve year follow-upfunctional results. Int J Colorectal Dis1994; 9: 11013.

107 Halverson AL, Hull TL. Long-term outcome of overlapping analsphincter repair. Dis Colon Rectum2002; 45: 34548.

108 Malouf AJ, Norton CS, Engel AF, Nicholls RJ, Kamm MA. Long-term results of overlapping anterior anal-sphincter repair forobstetric trauma. Lancet2000; 355: 26065.

109 Rothbarth J, Bemelman WA, Meijerink WJ,Buyze-Westerweel ME, van Dijk JG, Delemarre JB. Long-termresults of anterior anal sphincter repair for fecal incontinence dueto obstetric injury. Dig Surg 2000; 17: 39093.

110 Sangwan YP, Coller JA, Barrett RC, et al. Unilateral pudendalneuropathy: impact on outcome of anal sphincter repair. Dis ColonRectum 1996; 39: 68689.

111 Pinedo G, Vaizey CJ, Nicholls RJ, Roach R, Halligan S, Kamm MA.Results of repeat anal sphincter repair. Br J Surg 1999; 86: 6669.

112 Giordano P, Renzi A, Efron J, et al. Previous sphincter repair doesnot affect the outcome of repeat repair. Dis Colon Rectum2002; 45:63540.

113 Devesa JM, Vicente E, Enriquez JM, et al. Total fecalincontinencea new method of gluteus maximus transposition:preliminary results and report of previous experience with similarprocedures. Dis Colon Rectum1992; 35: 33949.

114 Konsten J, Baeten CGMI, Havenith MG, Soeters PB. Morphologyof dynamic graciloplasty compared with the anal sphincter.Dis Colon Rectum1993; 36: 55963.

115 Baeten C, Spaans F, Fluks A. An implanted neuromuscularstimulator for fecal continence following previously implantedgracilis muscle: report of a case. Dis Colon Rectum1988; 31:13437.

116 Madoff RD, Rosen HR, Baeten CG, et al. Safety and efcacyof dynamic muscle plasty for anal incontinence: lessons from aprospective, multicenter trial. Gastroenterology1999; 116: 54956.

117 Baeten CG, Bailey HR, Bakka A, et al. Safety and efcacy of dynamic graciloplasty for fecal incontinence: report of a prospective,multicenter trial. Dis Colon Rectum2000; 43: 74351.

118 Christiansen J, Lorentzen M. Implantation of articial sphincter foranal incontinence. Lancet1987; 2: 24445.

119 Altomare DF, Dodi G, La Torre F, Romano G, Melega E, Rinaldi M.Multicentre retrospective analysis of the outcome of articial analsphincter implantation for severe faecal incontinence. Br J Surg 2001; 88: 148186.



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Review

120 OBrien PE, Skinner S. Restoring control: the Acticon Neosphincterarticial bowel sphincter in the treatment of anal incontinence.Dis Colon Rectum2000; 43: 121316.

121 Christiansen J, Rasmussen OO, Lindorff-Larsen K. Long-termresults of articial anal sphincter implantation for severe analincontinence. Ann Surg 1999; 230: 4548.

122 Wong WD, Jensen LL, Bartolo DC, Rothenberger DA. Articial analsphincter. Dis Colon Rectum1996; 39: 134551.

123 Lehur PA, Roig JV, Duinslaeger M. Articial anal sphincter:prospective clinical and manometric evaluation. Dis Colon Rectum2000; 43: 110006.

124 Malouf AJ, Vaizey CJ, Kamm MA, Nicholls RJ. Reassessing articialbowel sphincters. Lancet2000; 355: 221920.

125 Wong WD, Congliosi SM, Spencer MP, et al. The safety and efcacyof the articial bowel sphincter for fecal incontinence: results froma multicenter cohort study. Dis Colon Rectum2002; 45: 113953.

126 Matzel KE, Stadelmaier U, Hohenfellner M, Gall FP. Electricalstimulation of sacral spinal nerves for treatment of faecalincontinence. Lancet1995; 346: 11247.

127 Matzel KE, Stadelmaier U, Hohenfellner M, Hohenberger W.Chronic sacral spinal nerve stimulation for fecal incontinence: long-term results with foramen and cuff electrodes. Dis Colon Rectum2001; 44: 5966.

128 Matzel KE, Kamm MA, Stosser M, et al. Sacral spinal nervestimulation for faecal incontinence: multicentre study. Lancet2004;363: 127076.

129 Vaizey CJ, Kamm MA, Turner IC, Nicholls RJ, Woloszko J. Effectsof short term sacral nerve stimulation on anal and rectal function inpatients with anal incontinence. Gut 1999; 44: 40712.

130 Malouf AJ, Vaizey CJ, Nicholls RJ, Kamm MA. Permanent sacralnerve stimulation for fecal incontinence. Ann Surg 2000; 232:14348.

131 Ganio E, Ratto C, Masin A, et al. Neuromodulation for fecalincontinence: outcome in 16 patients with denitive implant: the

initial Italian Sacral Neurostimulation Group (GINS) experience.Dis Colon Rectum2001; 44: 96570.

132 Matzel KE, Kamm ME, Stosser M, et al. Sacral spine nervestimulation for faecal incontinence: multicentre study. Lancet2004; 363: 127076.

133 Rosen HR, Urbarz C, Holzer B, Novi G, Schiessel R. Sacral nervestimulation as a treatment for fecal incontinence. Gastroenterology2001; 121: 53641.

134 Feretis C, Benakis P, Dailianas A, et al. Implantation of microballoons in the management of fecal incontinence.Dis Colon Rectum2001; 44: 160509.

135 Weiss E, Efron J, Nogueras J, Wexner S. Submucosal injection of carbon-coated beads is a successful and safe ofce-basedtreatment of fecal incontinence. Dis Colon Rectum2002; 45:A4647 (abstr).

136 Shak A. Perianal injection of autologous fat for treatmentof sphincteric incontinence. Dis Colon Rectum1995; 38:58387.

137 Malouf AJ, Vaizey CJ, Norton CS, Kamm MA. Internal analsphincter augmentation for fecal incontinence using injectablesilicone biomaterial. Dis Colon Rectum2001; 44: 595600.

138 Kumar D, Benson MJ, Bland JE. Glutaraldehyde cross-linkedcollagen in the treatment of faecal incontinence. Br J Surg 1998;85: 97879.

139 Keneck NJ, Vaizey CJ, Malouf AJ, Norton CS, Marshall M,Kamm MA. Injectable silicone biomaterial for faecal incontinencedue to internal anal sphincter dysfunction. Gut 2002; 51:22528.

140 Takahashi T, Garcia-Osogobio S, Valdovinos MA, Belmonte C,Barreto C, Velasco L. Extended two-year results of radio-frequencyenergy delivery for the treatment of fecal incontinence (the Seccaprocedure). Dis Colon Rectum2003; 46: 71115.

141 Efron J, Corman ML, Fleshman J, et al. Safety and effectivenessof temperature-controlled radio-frequency energy delivered tothe anal canal (Secca procedure) for the treatment of fecalincontinence. Dis Colon Rectum2003; 46: 160616.


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