Fecal Incontinence

Fecal incontinence is a common problem in the population with a devastating effect on quality of life. Initial work-up involves a thorough history and physical exam with a trial of conservative therapy. If conservative measures prove ineffective, the patient should undergo a pelvic floor evaluation including anal manometry, anal endosonography, and defecography to rule out potentially surgically ameliorated fecal incontinence. For patients who have a discrete sphincter defect, an overlapping sphincteroplasty can provide significant improvement in continence. For those patients without a sphincter defect or for those who fail sphincter repair, a trial of sacral neuromodulation (SNM) is merited. For those patients for whom SNM is inadequate, there are a variety of sphincter augmentation procedures including Secca® radiofrequency energy application, anal sphincter injectables, muscle transpositions, artificial bowel sphincter, or magnetic anal sphincter. For those who fail all therapies, permanent colostomy can provide relief from intractable fecal incontinence. Figure 9.6 shows a flow-chart showing the evaluation and treatment decision-making for patients with fecal incontinence.