both self‐directed and with the assistance of a physiotherapist, aims to strengthen the pelvic floor muscles and therefore increase anal tone. In a typical protocol, the patient may be instructed to squeeze for 10 seconds while continuing to breathe deeply so that the abdominal wall muscles do not also contract. Ten to 20 such 10–second squeezes are separated by 20‐second periods of pelvic floor relaxation. Patients are instructed to squeeze 10–20 times in a block and to repeat this block of exercises three to five times a day, with both ‘quick’ squeezes lasting one second and ‘slow” squeezes held for up to 10 seconds. The patient may be taught how to perform this exercise using only verbal or written instructions, or the therapist may give them verbal feedback on their performance during a digital rectal examination.57 Pelvic floor exercise has been shown to be effective for urinary incontinence in women with cognitive impairment58 but has not been studied for faecal incontinence in this group.
Biofeedback is classically described as a learning theory with operant conditioning and was first described by Engel and colleagues in the 1970s.59 Biofeedback is a nonsurgical, non‐invasive, relatively inexpensive outpatient method of treating faecal incontinence. During biofeedback, patients are given verbal feedback and shown a visual representation of anal canal pressure, measured with a manometer. This allows people to relearn to effectively contract the external sphincter while keeping the abdominals relaxed and to recognize the sensation of rectal distention.60 The evidence for biofeedback is mixed, with many small studies of generally poor quality. In a 2001 review of 46 studies involving the use of biofeedback for faecal incontinence in 1364 patients (76% female), fewer than 20% of these studies included randomization, and most involved relatively small numbers of subjects. Improvement in continence occurred in at least half of the patients. No specific details regarding age‐related differences were noted.61 A randomized controlled trial (RCT) comparing ‘standard care’ – specifically, bowel habit advice, advice and instruction on pelvic floor exercises, hospital‐based computer‐assisted sphincter pressure biofeedback, and hospital‐based computer‐assisted sphincter pressure biofeedback with home biofeedback – found that conservative therapy improved continence and quality of life, with around half of participants improving, but no additional benefit from biofeedback.62 A Cochrane Review in 201263 concluded that
[There is] no evidence that one method of biofeedback or exercises gives any benefit over any other method, but biofeedback or electrical stimulation may offer an advantage over exercises alone if patients have previously failed to respond to other conservative managements. Addition of biofeedback to surgical sphincter repair does not appear to improve the outcome … there is not enough evidence on which to select patients suitable for anal sphincter exercises or biofeedback, or both; nor to know which modality of biofeedback or exercises is optimal … Based on the available evidence these conclusions can only be tentative. No study reported any adverse events or deterioration in symptoms, and it seems unlikely that these treatments may cause any harm.
Given that pelvic floor muscle exercises, physiotherapy, and biofeedback are non‐invasive and safe, they are worthy of attempting in those with reduced anal tone or passive leakage, especially if other conservative measures have failed and in those unfit for surgical intervention.
Surgical therapy
Surgical intervention is generally only considered in those for whom there is a demonstrable anatomical defect in the sphincter and where other measures have failed. Although more readily considered in younger patients, age alone should not be considered a barrier to surgical treatment of faecal incontinence. A careful assessment of the individual’s general health and frailty and the risks and benefits of surgery should be considered before undertaking an operation, and realistic goal‐setting is essential.
Sphincter repair
Anterior sphincteroplasty can be very successful and is the operation of choice when an isolated sphincter defect is present.64 Reported rates of continence post‐surgery range from 50 to 90%, with the majority of studies being small‐scale case series, often in relatively young people. The International Continence Society concludes that
Anal sphincteroplasty should be considered in symptomatic patients with a defined defect in the external anal sphincter. Overlapping EAS repair is usually performed. Results appear to deteriorate with time. Redo sphincter repair may be feasible in patients with a poor continence outcome.54
The evidence for sphincteroplasty in older adults is lacking, particularly in those with frailty. A case series in 2006 involving 66 women undergoing surgery at a mean age of 62.8 found no association between age and result, with three‐quarters of participants reporting improvement.65
Neosphincter operations
The creation of a neosphincter using transplanted muscle may be considered in more severe faecal incontinence when other approaches have failed. Autologous muscle, usually gracilis or gluteus maximus, is transposed to form a new sphincter. The technique is limited by the physiology of the transposed muscle; the native anal sphincter is tonically contracted without effort, whereas the neosphincter requires conscious input to contract. In addition, the gracilis and gluteus maximus are largely type II fast‐twitch fibres, and the external anal sphincter consists of type I slow‐twitch, fatigue‐resistant fibres. These limitations can be overcome with electrical stimulation of the neosphincter, but the procedure has largely been superseded by sacral neuromodulation.54
Sacral neuromodulation
Sacral nerve stimulation (SNS), also known as sacral neuromodulation, was first described in 1995.66 Although the mechanism of action is not completely understood, electrical stimulation of the sacral nerve via an implanted generator and electrode (normally in the S3 foramen) increases the resting tone of the anus and, therefore, reduces incontinence.67 Multiple small case series in selected patients have shown benefit; a Cochrane Review identified six crossover trials, concluding that the limited available evidence suggests that SNS can improve continence in a portion of patients with faecal incontinence. The largest randomized trial included 120 patients, 60 receiving SNS and 60 control, with ages ranging from 39 to 86 and a mean age of 63.5. With sacral nerve stimulation, incontinent episodes per week decreased from an average of 9.5 to 3.1, and mean incontinent days per week from 3.3 to 1. Complete continence was accomplished in 25 patients. There was no improvement in the control group at 12 months.68
Faecal diversion
If all else fails, diversion of faeces with colostomy or ileostomy can be considered. It allows reliable containment of faecal matter, but the individual’s ability to manage a stoma both at the time and in the future should be taken into consideration.
Containment
Incontinence pads are designed to hold urine and are often ineffective for faeces. In those with cognitive impairment who cannot alert caregivers to an episode of incontinence, regular checking is essential to prevent skin damage. Products and devices that redirect or store faeces are available and most commonly used in bedridden or immobile patients with diarrhoea.69 Anal plugs consist of a cup‐shaped piece of foam held into a tight shape by soluble film. When inserted into the rectum, the film dissolves, allowing the plug to expand and prevent the leakage of stool. Such plugs are often uncomfortable, but in those patients able to tolerate them, they provide excellent, though temporary, control.70,71 They are not suitable for those with active proctocolitis or spinal cord injury. The selection of containment is a very individual decision and involves both patient factors and consideration of availability and cost of devices. The website www.continenceproductadvisor.org
