Evaluation and Treatment of FI
Fecal incontinence (FI) is a common condition, affecting nearly 10 % of women over age 45 at least once per month. A thorough history of precipitating factors, obstetric history, and prior surgical history are important components of the workup of FI. Onc
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Key Concepts • A thorough history and physical examination, followed by a trial of conservative measures is the first step to managing FI. • Preoperative physiology testing may aid in selection of treatment modalities, but does not predict the outcome of treatment. • Overlapping sphincteroplasty is a successful treatment in patients with complete sphincter disruption. • Sacral neuromodulation has been demonstrated to be successful in patients with and without a sphincter defect. • Biomaterial injection and radiofrequency energy delivery appear to provide modest benefit in incontinence scores, but further data is needed to substantiate this. • The artificial bowel sphincter has demonstrated excellent improvement in incontinence scores, but complications and need for revisions prevent it from being a first line treatment for FI.
Introduction Fecal incontinence (FI) is defined as the uncontrolled passage of feces or gas [1–4]. It is estimated that at least 18 million adults in the USA suffer from FI, while these figures appear to approach 50 % in institutionalized patients and this is frequently cited as the precipitating reason to transfer to nursing homes [5–7]. Recently, Brown et al. used Neilson data to conduct a survey of >6000 women in the USA older than 45 years with an impressive 86 % response rate [8]. Their results indicated that nearly 20 % of respondents experience episodes of Electronic supplementary material: The online version of this chapter (doi:10.1007/978-3-319-25970-3_61) contains supplementary material, which is available to authorized users.
FI at least once per year, while 9.5 % experienced FI at least once per month [8]. This study also demonstrated that patients prefer the term “accidental bowel leakage” rather than fecal incontinence. Prevalence estimates are thought to be conservative since a recent survey indicated that only 28 % of these patients have ever discussed their symptoms with a physician [9]. Of those who did seek care, over 75 % sought care with an internist or family physician, while only 7 % discussed their concerns with a colorectal surgeon [9]. Normal continence is a complex interaction between sensory function, sphincter muscle function, pelvic floor muscle coordination, rectal compliance, and consistency of stool. Failure of any of these mechanisms can lead to impaired continence. The most common historical factor is often prior obstetric trauma in a female [10]. Sphincter disruption from obstetric injury is observed clinically in approximately 10 % of all vaginal deliveries, but occult sphincter damage may be identified in up to 21–35 % of vaginal deliveries. Additionally, other possible causes include sphincter damage from prior anorectal surgery such as fistulotomy, lateral internal sphincterotomy, denervation of the pelvic floor from pudendal nerve injury during childbirth, chronic rectal prolapse, neurologic conditions (spina bifida, or myelomeningocele), or a noncompliant rectum from inflammatory bowel disease, or radiation proctitis [4, 10]. A careful history can be helpful
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