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Surgical Management of Anal Incontinence

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Pelvic Floor, Perineal, and Anal Sphincter Trauma During Childbirth

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Abstract

In most cases, conservative therapy should be the first line treatment for those with anal incontinence. In very selected patients, such as women in the post-partum period who have suffered an obstetric anal sphincter injury (OASI) and have a wound infection or breakdown, anal sphincter repair may be offered. There is evidence that the effectiveness of this operation will wane over time. Artifical anal sphincter devices are no longer routinely offered. Sacral neuromodulation is the most effective treatment available for those who do not improve with conservative measures and remains effective in the long term. However, its exact mechanism of action remains elusive. New anal injectable devices and regenerative medicine therapies may offer some promise. For those who fail all other therapies, a stoma may be the last resort of use.

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Author information

Authors and Affiliations

  1. St Mark’s Hospital, London, UK

    Gregory Thomas & Carolynne Vaizey

  2. Department of surgery and cancer, Imperial College of London, London, UK

    Carolynne Vaizey

Authors
  1. Gregory Thomas
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  2. Carolynne Vaizey
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Corresponding author

Correspondence to Gregory Thomas .

Editor information

Editors and Affiliations

  1. Croydon University Hospital, London, UK

    Abdul H. Sultan

  2. Croydon University Hospital, London, UK

    Ranee Thakar

  3. Obstetrics and Gynecology; Section of Urogynecology and Reconstructive Pelvic Surgery, University of Chicago, Chicago, IL, USA

    Christina Lewicky-Gaupp

Appendix: MCQ

Appendix: MCQ

Mark each item TRUE or FALSE

20.1.1 Questions

  1. 1.

    Anal incontinence is

    1. (A)

      More common in men

    2. (B)

      Linked to significant obstetric trauma

    3. (C)

      Always best managed with surgery

    4. (D)

      Often associated with other pelvic floor disorders

    5. (E)

      Likely to have a significant impact on quality of life of those affected

  2. 2.

    Regarding assessment and management of anl incontinence:

    1. (A)

      A rectal prolapse found at presentation may be left for conservative treatment

    2. (B)

      Lower GI endoscopy is indicated if rectal bleeding and/or a recent change in bowel habit is reported

    3. (C)

      Chronic loose stool should be investigated and corrected in the early stages of treatment

    4. (D)

      Endoanal ultrasonography may help determine what treatment may be offered

    5. (E)

      Biofeedback/ pelvic floor nursing therapy is unhelpful in most cases

  3. 3.

    Secondary anal sphincter repair:

    1. (A)

      May be offered for any type of sphincter defect

    2. (B)

      Maintains good outcomes in the long term for the majority

    3. (C)

      Requires prior endoanal ultrasonography and assessment of sphincter function

    4. (D)

      A covering colostomy should be used for all cases

    5. (E)

      May be combined with a soft tissue flap in the presence of significant perineal tissue loss

  4. 4.

    Sacral neuromodulation

    1. (A)

      Has a clearly defined mechanism of action

    2. (B)

      May be performed under local anaesthesia

    3. (C)

      Can be offered to those with a sphincter defect

    4. (D)

      Typically has a test stage

    5. (E)

      Once the device has been implanted, the patient may be discharged without the need for follow up

  5. 5.

    Regarding other surgical options for anal incontinence

    1. (A)

      There are a wide range of artificial anal sphincter devices currently available

    2. (B)

      Antegrade colonic enemas (ACE) are well tolerated in adults, with few complications

    3. (C)

      The “Sphinkeeper” anal injectable requires endoanal ultrasonography to achieve optimal device placement

    4. (D)

      A diverting colostomy should always be considered a “last resort” for those with severe faecal incontinence

    5. (E)

      Mucus leakage may persist after a colostomy

20.1.2 Answers

  1. 1.

    Anal incontinence is

    1. (A)

      FALSE

    2. (B)

      TRUE

    3. (C)

      FALSE

    4. (D)

      TRUE

    5. (E)

      TRUE

  2. 2.

    Regarding assessment and management of anl incontinence:

    1. (A)

      FALSE

    2. (B)

      TRUE

    3. (C)

      TRUE

    4. (D)

      TRUE

    5. (E)

      FALSE

  3. 3.

    Secondary anal sphincter repair:

    1. (A)

      FALSE

    2. (B)

      FALSE

    3. (C)

      TRUE

    4. (D)

      FALSE

    5. (E)

      TRUE

  4. 4.

    Sacral neuromodulation

    1. (A)

      FALSE

    2. (B)

      TRUE

    3. (C)

      TRUE

    4. (D)

      TRUE

    5. (E)

      FALSE

  5. 5.

    Regarding other surgical options for anal incontinence

    1. (A)

      FALSE

    2. (B)

      FALSE

    3. (C)

      TRUE

    4. (D)

      FALSE

    5. (E)

      TRUE

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Thomas, G., Vaizey, C. (2024). Surgical Management of Anal Incontinence. In: Sultan, A.H., Thakar, R., Lewicky-Gaupp, C. (eds) Pelvic Floor, Perineal, and Anal Sphincter Trauma During Childbirth. Springer, Cham. https://doi.org/10.1007/978-3-031-43095-4_20

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  • DOI: https://doi.org/10.1007/978-3-031-43095-4_20

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  • Publisher Name: Springer, Cham

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  • Online ISBN: 978-3-031-43095-4

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