Sphincter repair or Sacral Nerve Modulation: Still debatable?

Abstract

Fecal incontinence (FI) is a debilitating condition with negative consequences to patients. It is recognized as a “quality of life” illness. Sphincter tears resulting often from difficult childbirth or from surgical trauma, are well-identified causes of FI. When conservative measures fail to resolve FI symptoms, a surgical treatment is recommended on the basis of a comprehensive pelvic floor work-up. A sphincter tear is frequently found on endoanal ultrasonography. The best way to surgically approach a patient with FI related/associated with a sphincter lesion is still debatable. International guidelines are inconsistent regarding the role of either sacral neuromodulation (SNM) or anal sphincteroplasty (anal sphincter repair) (AS) in patients with anal sphincter defect. Decision making for an individual patient often relies on expert opinion and personal experience due to the poor quality of the few published studies. Currently the presence of a sphincter defect is no longer considered a contraindication for sacral nerve modulation (SNM) which has several advantages. SNM is a minimally invasive procedure with very low morbidity, its results can be accurately predicted with a test phase, and are sustained with long-term placement of the implant. Nevertheless, AS has clearly a role to play, for instance in young female patients reluctant to get an implanted nerve stimulator early in life and/or in case of a cloacae-like deformity as a sequela of a post-obstetrical 4th degree tear. While waiting for prospective studies directly comparing SNM and AS for various types of FI, we propose in this paper a pragmatic treatment algorithm based on the most recently published studies and recommendations for the management of sphincter defect related/associated FI.