Inside Tract - New Treatments for Fecal Incontinence
New Treatments for Fecal Incontinence
Date: July 5, 2013
Ten years ago,” muses gastroenterologist Ellen Stein, “about all we could therapeutically offer patients with fecal incontinence (FI) were the extremes.” On one hand were suggestions that patients adopt diets geared to bulk up the stool or arrange a morning enema before setting out—mild tactics, certainly. On the other, in rare, extreme cases of FI—the sort that might come after, say, neurological damage or cancer—there was colostomy.
Now that’s changed significantly. And as clinicians who treat a condition that’s fraught with psychological or social shame, Stein says, she and colleagues with the Johns Hopkins motility service “are relieved.”
Two recently FDA-approved approaches now offered as outpatient procedures improve quality of life for patients. One uses a sterile, injectable gel to bulk up the perianal area. The gel is a natural oligosaccharide, long a workhorse in plastic surgery practice.
“We see a lot of younger women with FI who’ve had difficult deliveries and suffered obstetric trauma,” says gastroenterologist Patrick Okolo, who introduced the technique for FI to Baltimore. Injected into the submucosal layer of the anal canal, the gel closes the gap between the canal and buttocks, a common site of obstetric injury. “The extra ‘tissue’ improves a patient’s ability to grip with the sphincter, even with limited strength, and get to the bathroom,” says Stein. She, like Okolo, is certified in the procedure.
“The gel resists breaking down, so treatment typically lasts a year or two,” Okolo says. “It offers an extra level of control and restores a measure of natural strength to sphincter action. It’s not a panacea. But the gel is extremely effective when part of comprehensive treatment.”
Sacral Nerve Stimulation
The other new therapy, sacral nerve stimulation, is a surgical procedure originally developed for urinary incontinence. “But many patients reported it worked better for their rectal problems,” says Susan Gearhart, the service’s colorectal surgeon. “With the tactic, patients can get 100 percent control.” She cites a study that shows 80 percent of patients have FI episodes reduced at least by half. And in 40 percent of those, they stop altogether. Like the injectable gel, placement of the “interstim” device is an outpatient procedure that is safe and well-tolerated.
To reach the target nerve, Gearhart eases an electrode into a small incision in the buttocks. She feeds it under the skin and guides it by fluoroscopy through a pelvic foramen to rest on the S3 nerve overseeing the sphincter. Because permanently securing the attached battery pack means implanting it in the buttocks, patients first get a two-week trial of neurostimulation with an external pack.
Nothing happens for either therapy without what Okolo calls “a short but deep evaluation” because patients with FI are so heterogeneous. Disease history will tell who needs anorectal manometry or ultrasound to verify sphincter strength. Stein may also ask patients to keep a bowel habits diary. It helps alert her to patients “who resort to intuitive but unhelpful behaviors like overusing muscles to retain stool.”
“We work together,” adds Okolo, “to keep patients from depending on Depends.”