Sacral nerve stimulation for treatment of fecal incontinence in a patient with muscular dystrophy: report of a case.

Fecal incontinence is a common condition that causes major impairment of social life. Sacral nerve stimulation is a promising treatment in idiopathic fecal incontinence when conventional treatments have failed. However, new indications for sacral nerve stimulation are emerging. The present case shows that sacral nerve stimulation for treatment of fecal incontinence may be justified in other diseases in which fecal incontinence is a major problem.

Sacral nerve stimulation in fecal incontinence.

PURPOSE: The effect of sacral nerve stimulation was studied in 45 patients with fecal incontinence. METHODS: All patients were initially tested in general anesthesia. Sacral nerves 2, 3, and 4 were tested on both sides. If a perineal/perianal muscular response to sacral nerve stimulation could be obtained, electrodes were implanted for a three-week test-stimulation period. If sacral nerve stimulation resulted in at least a 50 percent reduction in incontinence episodes during the test period, a system for permanent sacral nerve stimulation was implanted. RESULTS: When tested in general anesthesia, 43 of 45 patients had a muscular response to sacral nerve stimulation and had electrodes implanted for the three-week test period. Percutaneous electrodes were used in 34 patients, and 23 of these had at least a 50 percent reduction in incontinence episodes, whereas the electrodes dislocated in 7 patients and 4 had a poor response. Permanent electrodes with percutaneous extension electrodes were used primarily in 9 patients and after dislocation of percutaneous electrodes in an additional 6 patients; 14 of these had a good result. In the last patient, no clinical response to stimulation with the permanent electrode could be obtained. A permanent stimulation system was implanted in 37 patients. After a median of six (range, 0-36) months follow-up, five patients had the system explanted: three because the clinical response faded out, and two because of infection. Incontinence score (Wexner, 0-20) for the 37 patients with a permanent system for sacral nerve stimulation was reduced from median 16 (range, 9-20) before sacral nerve stimulation to median 6 (range, 0-20) at latest follow-up ( P < 0.0001). There was no differences in effect of sacral nerve stimulation in patients with idiopathic incontinence (n = 19) compared with spinal etiology (n = 8) or obstetric cause of incontinence (n = 5). Sacral nerve stimulation did not influence anal pressures or rectal volume tolerability. CONCLUSIONS: Sacral nerve stimulation in fecal incontinence shows promising results. Patients with idiopathic, spinal etiology, or persisting incontinence after sphincter repair may benefit from this minimally invasive treatment.

Fecal incontinence. Studies on physiology, pathophysiology and surgical treatment.

The thesis consists of ten previously published studies and a review. The physiological and pathophysiological mechanisms in fecal incontinence has been studied by anal manometry, both by standard static anal manometry and by a new method, dynamic anal manometry, where anal sphincter pressure can be measured during simultaneous opening and closing of the anal canal. Patients with fecal incontinence showed abnormal sphincter pressures more frequently when dynamic anal manometry was used compared to standard anal manometry. The physiology and pathophysiology of the rectum was studied using rectal compliance measurements. Patients with normal anorectal function had a large variation in rectal compliance. Patients with fecal incontinence had as a group, lower rectal compliance than continent patients. This may lead to increased frequency of incontinence episodes in patients with fecal incontinence. The relationship between idiopathic fecal incontinence and pudendal nerve terminal latency was studied in 178 patients. The far majority of patients had normal latencies, and there was no correlation between latency and anal manometry. In contrast to previous suggestions, idiopathic fecal incontinence does not seem to be caused by pudendal nerve damage. Reconstruction of the external anal sphincter in patients with fecal incontinence due to obstetric sphincter lesion showed a poorer functional result among patients older than forty years compared to younger. This indicates that the general muscular weakening with age contribute to the incontinence in these patients. The treatment of more complicated forms of fecal incontinence consists of, apart from conservative treatment or colostomi, mainly in muscle transpositions or artificial anal sphincter. Transposition of the distal part of the gluteus maximus muscle to encircle the anal canal, did not lead to acceptable continence in any of the patients studied. Transposition of the gracilis muscle lead to acceptable continence in half the patients. Patients where the transposed muscle were stimulated by a neurostimulator had satisfactory continence in most cases. However, with this method several re-operations were necessary in some patients. In addition, some patients developed severe evacuation difficulties. Implantation of an artificial sphincter resulted in long-term improvement of continence in that half of patients in whom the artificial sphincter remained implanted. The other half of the patients had the artificial sphincter explanted due to various reasons, most frequently due to infection around the device. In selected patients with more complicated fecal incontinence, stimulated gracilis transposition or implantation of an artificial anal sphincter may be offered as an alternative to colostomy. Sacral nerve stimulation is a new method which seems to provide the best results among the more advanced procedures. Its minimally invasive character also contribute to the increasing use of this method in the last few years. Evaluation and treatment of fecal incontinence is presently in a state of rapid change with focus on more elaborate investigative methods and more diversified treatment.

[Sacral nerve stimulation in fecal incontinence]. / Sakralnervestimulation ved analinkontinens.

INTRODUCTION: Sacral nerve stimulation for the treatment of faecal incontinence has gained increasing use in Europe over the last two years. Experience with the first patients treated in Denmark is described here. MATERIAL AND METHODS: Fourteen patients with severe faecal incontinence were given sacral nerve stimulation. The first treatment was temporary, and if this was successful they had a device for permanent stimulation implanted. RESULTS: The result of the test stimulation was good in ten of the 14 patients and a permanent system was implanted. After a median of 4.5 months' stimulation, nine of the ten patients continued to respond to respond well. DISCUSSION: Sacral nerve stimulation in the treatment of faecal incontinence shows promising results. Compared to other more advanced forms of treatment, this method is minimally invasive.