Is a morphologically intact anal sphincter necessary for success with sacral nerve modulation in patients with faecal incontinence?

Abstract

Objective Sacral nerve modulation (SNM) for the treatment of faecal incontinence was originally performed in patients with an intact anal sphincter or after repair of a sphincter defect. There is evidence that SNM can be performed in patients with faecal incontinence and an anal sphincter defect.Method Two groups of patients were analysed retrospectively to determine whether SNM is as effective in patients with faecal incontinence associated with an anal sphincter defect as in those with a morphologically intact anal sphincter following anal repair (AR). Patients in group A had had an AR resulting in an intact anal sphincter ring. Group B included patients with a sphincter defect which was not primarily repaired. Both groups underwent SNM. All patients had undergone a test stimulation percutaneous nerve evaluation (PNE) followed by a subchronic test over 3 weeks. If the PNE was successful, a permanent SNM electrode was implanted. Follow-up visits for the successfully permanent implanted patients were scheduled at 1, 3, 6 and 12 months and annually thereafter.Results Group A consisted of 20 (19 women) patients. Eighteen (90%) had a positive subchronic test stimulation. Twelve patients had a successful SNM implant during middle-term follow-up. Group B consisted of 20 women. The size of the defect in the anal sphincter varied between 17% and 33% of the anal circumference. Fourteen (70%) had a positive subchronic test stimulation. Twelve patients had a successful SNM implant during middle-term follow-up. In both groups, the mean number of incontinence episodes decreased significantly with SNM (test vs baseline: P = 0.0001, P = 0.0002). There was no significant difference in resting and squeeze pressures during SNM in group A, but in group B squeeze pressure had increased significantly at 24 months. Comparison of patient characteristics and outcome between groups A and B revealed no statistical differences.Conclusion A morphologically intact anal sphincter is not a prerequisite for success in the treatment of faecal incontinence with SNM. An anal sphincter defect of <33% of the circumference can be effectively treated primarily with SNM without repair.

Sacral nerve stimulation for fecal incontinence

“…Several authors have reported good results in this type of patients with non-repaired external sphincter (23,24), and our experience confirms this. In our perspective two aspects remain to be defined along this line of work.…”

Sakralnervestimulering

“…The PNE test is conducted over a period of 2-3 weeks. A positive test response is achieved for 70 %-90 % of patients (19)(20)(21)(22). In those who have an implanted stimulator, the effect is sustained in 70 %-90 % after 2-5 years (19,22,23).…”

“…Patients with sphincter lesions covering up to one-third of the circumference can benefit from sacral nerve stimulation (20). However, sphincter lesions detected by ultrasound are a negative predictor of success (28), and large sphincter defects should probably first be treated by way of sphincter reconstruction.…”

A Different Option for Neuromodulation Procedures: Sacral Nerve Stimulation

“…However, predictive factors that are necessary to reveal the efficacy of sacral neuromodulation prior to performing it remain to be unclear (33,34). The efficacy of sacral neuromodulation in partial sphincter injury has also been demonstrated (35)(36)(37). In patients with scleroderma having proctitis caused by radiation and reduced rectal compliance owing to inflammatory bowel syndrome and in patients with anterior resection or previous rectal prolapse colectomy, the efficacy of sacral neuromodulation is demonstrated only in few studies (38)(39)(40)(41)(42)(43).…”