Anal Sphincteroplasty

Abstract

Direct sphincter trauma or neuropathic injuries from vaginal deliveries are the principal causative factors in the development of fecal incontinence in women less than 40 years old [1]. Treatment options for the incontinent woman include anal sphincteroplasty, sacral nerve stimulation (SNS), artificial anal sphincter, posterior anal repair, and dynamic graciloplasty. Anal sphincteroplasty has been the preferred surgical treatment for the symptomatic female with an anatomically disrupted external anal sphincter (EAS) muscle. Short-term results report improved bowel incontinence as high as 90% [2, 3] with decreasing continence on long-term follow-up studies. Over the past decade, SNS has been utilized as a treatment modality with good results for patients with fecal incontinence with or without an anal sphincter defect [4–7], but SNS has only recently approved in the USA for this indication. The artificial anal sphincter, a silastic band surgically placed around the lower rectum, has been shown to improve bowel control. However, infection rates are reported at 33% [8, 9] leading to device failure or extrusion. Posterior anal repair is indicated for neuropathic incontinence and not very popular as its earlier results could not be duplicated. At best, only about 30% of the patients report improvement [10–12]. However, several long-term studies have shown favorable results [13, 14]. Dynamic graciloplasty is a complex procedure that involves gracilious muscle transposition and stimulation. This requires expertise; it is associated with a high morbidity and it is expensive [15–20]. This procedure is not an option in the United States since the stimulator used for muscle contraction is not commercially available. Other options include injectable bulking agents [21–24] into the anal sphincter which have shown to be effective in some studies, but are not presently approved in the USA for treatment of fecal incontinence. Transobturator insertion of a rectal sling has been reported with some success [25] and ongoing USA studies are in progress.KeywordsFecal IncontinenceAnal SphincterExternal Anal SphincterInternal Anal SphincterSacral Nerve StimulationThese keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.