The Use of Sacral Nerve Stimulation in Treatment of Rectal Incontinence: A Rare Case Report

Abstract

Rectal incontinence is the involuntary loss of solid or liquid feces and flatus. First step is to avoid foods with high quantities of fructose, lactose, and caffeine. Bulking agents like methylcellulose and antidiarrheal agents like loperamide are tried next to reduce stool consistency and frequency. If symptoms continue and anorectal manometry shows a weak anal sphincter, biofeedback therapy can be tried. Originally a treatment option for urinary incontinence and overactive bladder, minimally invasive sacral nerve stimulation (SNS) is now considered a therapeutic option in refractory rectal incontinence and has shown to provide relief of symptoms and have positive effects on quality of life. Presented is a case of a 79-year-old female with unresolved history of rectal incontinence since 2015. The initial symptom was minimal anal leakage while doing leisure activities such as gardening and shopping. She noted gradual increase in symptoms affecting daily life and causing social embarrassment, which forced her to wear diapers to disguise odor and staining. Diet change, bulking agents, and more recently, anal sphincteroplasty in 2017, failed to improve symptoms. She was warned that anal sphincteroplasty may not be effective due to her three vaginal deliveries and weak pelvic muscle function. Physical exam revealed incontinence during Valsalva. Digital rectal examination revealed weak pelvic muscles and poor anal tone. She has a remote smoking history of half a pack per day between the ages of 22 and 32 and admits to drinking 1-2 glasses of wine daily. She was offered sacral nerve stimulation. A temporary SNS electrode was implanted and she was told to keep a diary of her bowel movements for 4 weeks. She noted improvement and a permanent SNS device was placed. This case illustrates failed attempts of conservative treatments with the patient growing more ambivalent about controlling her symptoms in public. SNS is reserved for patients whose previous treatments have failed to alleviate symptoms. It involves placement of an electrode into the sacral foramen that sends low-grade electrical stimulations to the sacral nerve roots that innervate the anal sphincters and muscle wall. If a trial period with the temporary electrode relieves fecal incontinence, a permanent electrode is placed. It is because of the relationship of the anal sphincters and sacral innervation that candidates must have structurally intact anal sphincters for successful outcomes to be achieved.2945 Figure 1. Management Of Bowel Disorders