Surgery for faecal incontinence in adults

Brown SR, Wadhawan H, Nelson RL

Published Online:

September 8, 2010

Faecal incontinence (the inability to control the release of stool) can be debilitating, and is a common reason for older people to need nursing home care. It can happen for many reasons including malformations of the rectum (lower part of the intestine) or anus, neurological (nerve) diseases, or damage during childbirth or surgery. Treatments include pelvic floor muscle training, electrical stimulation, drugs and surgery. Surgery is used in selected groups of people particularly (but not exclusively) when the defects in the muscles surrounding the anal canal can be corrected mechanically. The review found that there is still not enough evidence on which to judge whether one type of surgical operation was better or worse than another one or better than different types of treatment for faecal incontinence. However, many of the techniques originally reviewed are now no longer in general use.

Abstract (click to read)

Background:

Faecal incontinence is a debilitating problem with significant medical, social and economic implications. Treatment options include conservative, non-operative interventions (e.g. pelvic floor muscle training, biofeedback, drugs) and surgical procedures. A surgical procedure may be aimed at correcting an obvious mechanical defect, or augmenting a functionally deficient but structurally intact sphincter complex.

Objectives:

To assess the effects of surgical techniques for the treatment of faecal incontinence in adults who do not have rectal prolapse. Our aim was firstly to compare surgical management with non-surgical management and secondly, to compare the various surgical techniques.

Search strategy:

Electronic searches of the Cochrane Incontinence Group Specialised Register (searched 26 November 2009), the Cochrane Colorectal Cancer Group Specialised Register (searched 26 November 2009), CENTRAL (The Cochrane Library 2009) and EMBASE (1 January 1998 to 30 June 2009) were undertaken. The British Journal of Surgery (1 January 1995 to 30 June 2009) Colorectal Diseases (1 January 2000 to 30 June 2009) and the Diseases of the Colon and Rectum (1 January 1995 to 30 June 2009) were specifically handsearched. The proceedings of the UK Association of Coloproctology meeting held from 1999 to 2009 were perused. Reference lists of all relevant articles were searched for further trials.

Selection criteria:

All randomised or quasi-randomised trials of surgery in the management of adult faecal incontinence (other than surgery for rectal prolapse).

Data collection and analysis:

Three reviewers independently selected studies from the literature, assessed the methodological quality of eligible trials and extracted data. The three primary outcome measures were: change or deterioration in incontinence, failure to achieve full continence, and the presence of faecal urgency.

Main results:

Thirteen trials were included with a total sample size of 440 participants. Two trials included a group managed non-surgically. One trial compared levator with anal plug electrostimulation and one compared artificial bowel sphincter with best supportive care. The artificial bowel sphincter resulted in significant improvements in at least one primary outcome but numbers were small. The other trial showed no difference in primary outcome measures.

Eleven trials compared different surgical interventions. These included anterior levatorplasty versus postanal repair, anterior levatorplasty versus total pelvic floor repair, total pelvic floor versus postanal repair, end to end versus overlap sphincter repair, overlap repair with or without a defunctioning stoma or with or without biofeedback, injection of silicone, hydrogel, physiological saline, carbon beads or collagen bulking agents, total pelvic floor repair versus repair plus internal sphincter plication and neosphincter formation versus total pelvic floor repair. Sacral nerve stimulation and injectables are also considered in separate Cochrane reviews. Only one comparison had more than one trial (total pelvic floor versus postanal repair, 44 participants) and no trial showed any difference in primary outcome measures.

Authors' conclusions:

Despite more studies being included in this update, the continued small number of relevant trials identified together with their small sample sizes and other methodological weaknesses continue to limit the usefulness of this review for guiding practice. It was impossible to identify or refute clinically important differences between the alternative surgical procedures. Larger rigorous trials are still needed. However, it should be recognised that the optimal treatment regime may be a complex combination of various surgical and non-surgical therapies.

This record should be cited as:

Brown SR, Wadhawan H, Nelson RL. Surgery for faecal incontinence in adults. Cochrane Database of Systematic Reviews 2010, Issue 9. Art. No.: CD001757. DOI: 10.1002/14651858.CD001757.pub3

Assessed as up to date:

November 26, 2009

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Primary Review Group:

Incontinence Group

Health topics:

Gastroenterology > Faecal incontinence > Surgery

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Surgery for faecal incontinence in adults

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