Treatment of fecal incontinence in the era of neuromodulation: is it time to rethink our approach?

Diseases of the Colon & ReCtum Volume 57: 9 (2014) fecal incontinence (fi), the involuntary loss of flatus or stool, is arguably the most socially and psychologically debilitating condition, with younger patients less likely to be in full employment and older patients more likely to be admitted into a care home. the condition is occasionally referred to as “the silent affliction,” because it may be kept a secret from family, friends, and physicians because of the social stigma attached to it. Despite significant underreporting, the national institute of Clinical excellence in the united Kingdom estimates that ≤10% of adults are affected, most commonly postpartum women because of pelvic floor weakness and anal sphincter disruption. the incidence of fi, however, is likely to increase in the future because of the shift in patient demographics toward older populations and the improvements in the surgical management of rectal cancer, which have resulted in a 3-fold increase in the number of long-term survivors over the past 3 decades. up to 90% of patients with rectal cancer may experience fi or urgency after pelvic radiotherapy or sphincter-preserving surgery. traditionally, fi is managed in specialist colorectal units with experience in procedures such as sacral nerve stimulation, sphincteroplasty, and electrically stimulated gracilis neosphincter, which are offered after failure of conservative measures (eg, diet and behavioral modification, constipating/ antimotility medication, and anal sphincter exercises with and without biofeedback) and before the eventual recourse of stoma formation for many patients. the outcome of these therapies is uncertain, but the patient commits for many years to a treatment pathway that is not necessarily compatible with his/her lifestyle, with repeated outpatient appointments, persistent or new symptoms, and postoperative complications to deal with. furthermore, the management for such patients is expensive, escalating to astronomical levels if surgery is undertaken. for example, the annual outpatient cost in the netherlands was €2169 (us $2972) per patient, whereas the average annual total cost for fi in the united states was $4110 per person, with higher annual direct costs for those with more severe symptoms. furthermore, the total charges associated with surgery in the united states increased from $34 million in 1998 to almost $60 million in 2003. in the united Kingdom, up to £100 million (us $168 million) is spent each year on treatments for the condition. if the prevalence of the condition increases as expected because of the increase in mean life expectancy and the increase in the number of patients who undergo sphincter-preserving rectal cancer surgery, the financial impact of such a benign condition on already limited healthcare resources is likely to be significant. Recently, accumulating evidence, mainly from small level iii studies, suggests that stimulation of the tibial nerve using a percutaneous or transcutaneous approach, to produce retrograde stimulation of the pelvic nerves, can be used to achieve symptom improvement. the percutaneous approach was found to be more effective than the transcutaneous route in a small, randomized controlled trial with short follow-up (6 months). in the largest study to date, with 119 patients receiving percutaneous tibial nerve stimulation, sustained improvements were seen in the clinical parameters (eg, incontinence score and deferment time), with >50% of patients experiencing a >50% reduction in incontinence episodes, with followup extending to 42 months. significantly, these improvements were accompanied by an increase in the quality-of-life scores, Treatment of Fecal Incontinence in the Era of Neuromodulation: Is It Time to Rethink Our Approach?