Pudendal nerve testing does not contribute to surgical decision making following anorectal testing in patients with faecal incontinence

Abstract

Independent predictors of surgical recommendation included the presence of prolapse, a functional sphincter length <1 cm, an external anal sphincter defect and a Cleveland Clinic Incontinence Score ≥ 10. Pudendal neuropathy was not a predictor of surgical intervention, leading us to question the utility of this investigation.

A Historical Perspective on Sacral Nerve Stimulation (SNS) for Bowel Dysfunction

“…In addition, sphincter repair procedures, post anal repair and total pelvic floor repair have proved ineffective in the long-term [4,13]. Those with severe neuropathic incontinence are best treated by intensive conservative management with control of stool consistency and physiotherapy or pelvic floor retraining (biofeedback) before surgical treatment is considered [16]. Biofeedback (behavioural) treatment is particularly useful in patients who have primarily a sensory problem in the anal canal leading to insensible loss of faeces.…”

Electrophysiological Basis of Fecal Incontinence and Its Implications for Treatment

“…Pudendal neuropathy is not a predictor of surgical intervention for fecal incontinence, but independent predictors include the presence of a prolapse, a functional sphincter length <1 cm, an external anal sphincter defect, and a Cleveland Clinic Incontinence Score ≥10 ( Table 2 ) [ 25 ]. In clinical assessments, pudendal nerve studies are of particular value in patients with fecal incontinence, but not in those with solitary rectal ulcer syndrome, hemorrhoids or the complexity of obstructive defecation syndrome as many of the associated problems or pathologies may not be immediately apparent.…”

“…The investigation only examines the fastest conducting fibers of the pudendal nerve, so the PNML can still be normal even in the presence of abnormal sphincter innervation [ 11 ]. Pudendal nerve testing may not, therefore, contribute to surgical decision making in patients with fecal incontinence [ 25 ]. The American Gastroenterology Association does not, therefore, recommend the use of pudendal nerve testing for the evaluation of patients with fecal incontinence [ 26 ].…”

“…However, many of these patients will have a degree of coexisting neuropathic damage to the pelvic floor, particularly if they have undergone multiple vaginal deliveries [ 38 ]. Although the presence of neuropathic damage in these patients does not alter the initial surgical management [ 25 ], it does influence the prognosis as seen in the poor long-term benefit (40%) from post anal repair or a total pelvic floor repair except for those with anatomical defects such as a rectocele or an abnormal perineal descent [ 39 40 ]. The etiology of the progression of the pudendal nerve damage over time is not known.…”

Pudendal nerve testing

“…The recent report on BPudendal nerve testing^is very interesting [1]. Cooper et al concluded that BPudendal nerve testing does not contribute to surgical decision making following anorectal testing in patients with faecal incontinence [1].^Cooper et al also questioned Bthe utility of this investigation [1].^In fact, pudendal nerve testing is a very classical physical examination and requires no cost for testing. Since it is a physical examination, it might be considered subjective, and the accuracy of the result also depends on the technique and experience of the practitioner [2,3].…”