Is there a role for concomitant pelvic floor repair in patients with sphincter defects in the treatment of fecal incontinence?

Abstract

More than half of all patients who undergo overlapping anal sphincter repair for fecal incontinence develop recurrent symptoms. Many have associated pelvic floor disorders that are not surgically addressed during sphincter repair. We evaluate the outcomes of combined overlapping anal sphincteroplasty and pelvic floor repair (PFR) vs. anterior sphincteroplasty alone in patients with concomitant sphincter and pelvic floor defects. We reviewed all patients with concomitant defects who underwent surgery between February 1998 and August 2001. Patients were assessed preoperatively by anorectal manometry, pudendal nerve terminal motor latency, and endoanal ultrasound. The degree of continence was assessed both preoperatively and postoperatively using the Cleveland Clinic Florida fecal incontinence score. Postoperative success was defined as a score of <or=5, whereas postoperative quality of life was assessed by a standardized questionnaire. Twenty-eight patients (mean age 52.3 years) underwent overlapping anal sphincteroplasty. The mean follow-up was 33.8 months. Cleveland Clinic Florida scores postoperatively showed a significant improvement from preoperative values (14.2 vs 5.1, p<0.001). Seventeen patients (61%) underwent concomitant PFR with sphincteroplasty. Three patients (27%) without PFR and one patient (6%) with PFR underwent repeat sphincter repair due to worsening symptoms (p=0.15). Two patients with PFR and one patient without PFR ultimately had an ostomy due to a failed repair (p=0.66). Comparing patients with and without PFR, there was a trend toward higher success rates (71 vs. 45%) when pelvic prolapse issues were addressed during sphincter repair. Concomitant evaluation and repair of pelvic floor prolapse may be a clinically significant component of a successful anal sphincteroplasty for fecal incontinence but warrant further prospective evaluation.