Fecal Incontinence: the uncontrolled release of gas or stool from the anus.
Anal sphincter: a series of circular muscles, the majority of which are under voluntary control, which prevent the release of gas or stool from the anus.
Sphincteroplasty: a surgical procedure performed to repair a tear in the anal sphincter.
Artificial anal sphincter: a device implanted under the skin which is designed to mimic the natural function of the anal sphincter.

Affecting nearly one million people, fecal incontinence is a common problem, most often caused by an injury to the anal sphincter during childbirth. The severity may vary from the infrequent passage of gas to daily passage of solid stool. Severe incontinence often interferes with the ability to work, enjoy social activities and is a frequent reason for nursing home placement. Despite this being a common and significant problem, most people with incontinence are uncomfortable discussing this with their family, friends or doctors. Instead, they suffer in silence not knowing what to do.

1. Initially, fecal incontinence is usually treated through one of the following means:
   Kegel exercises are repetitive efforts to tighten the anal sphincter muscles in an effort to strengthen them and make them more effective. These are performed several times throughout the day and require no equipment.
   Biofeedback is a method of retraining the existing anal sphincter to function as best as is possible. It involves several training sessions with a special sensor and display to demonstrate how well the muscle is working with certain efforts by the patient.
   Antidiarrheal medicine (fiber supplements, Imodium7, Lomotil7) is often prescribed to patients who have frequent or loose stools which are harder to control.
   Enemas can often be administered prior to a social activity. This treatment is useful in that it partially empties the large intestine of stool at a convenient time (when a bathroom is quickly available).
   
   
2. If initial attempts to control fecal incontinence fail, surgical means of treatment may be considered. Surgery may include sphincteroplasty and insertion of an artificial anal sphincter.
   
   The artificial anal sphincter device is a modification of the artificial urinary sphincter, manufactured by the same company, which has been used since 1972. It is best used when a sphincteroplasty has been tried and failed, or when a sphincteroplasty cannot be performed because sufficient healthy muscle is lacking.

Any operation involves three phases to complete the procedure. These are preparation, operation and postoperative care.

1. Preparation: Preparation for sphincteroplasty is designed to reduce the risk of infection at the sphincter repair site. The large intestine must be emptied of stool by a " bowel prep," which may take a few days to complete and require you to take special laxatives, depending on the particular method your surgeon prefers. Dietary changes (clear liquid diet) are usually begun at the time the bowel prep is started. You should not eat or drink after midnight the night before the operation for safety in administering the anesthesia for the operation. Intravenous antibiotics are given immediately before the operation to reduce the risk of infection.
    
2. Operation: To provide access to the anal area, you may be asked to lie on your back with your legs supported out to the side or on your stomach with a pad under your hips. The details of sphincteroplasty and implantation of the artificial anal sphincter are described in the next section.
    
3. Postoperative care: The major causes for breakdown of the sphincteroplasty are infection and the passage of a hard stool which can tear the stitches out of the fragile muscle. To reduce these risks, you may be required to stay in the hospital for a few days after surgery. You may be asked to follow dietary restrictions (nothing to eat or drink, or clear liquids only) and antidiarrheal medicine to bind the bowels. Intravenous antibiotics are often administered to help lower the risk of infection, and the skin incision is cleansed three times per day. After a few days, or the passage of stool, the medications are stopped and a regular diet resumed. At this point, the passage of a hard stool must be avoided. Stool softeners (Colace) or fiber supplements (Metamucil, Citrucel, Konsyl) and plenty of water are prescribed to keep the stool soft. Mineral oil is often used to avoid constipation, and Milk of Magnesia may be used as a gentle laxative if there has been two to three days between bowel movements. Nothing should be inserted in the anus (suppository, enema, thermometer) for about six weeks to avoid injury to the sphincteroplasty. For a period of two to three months, patients are asked to refrain from sexual intercourse, bicycle riding, intense physical exercise, heavy lifting and squatting.

Sphincteroplasty
A sphincteroplasty is usually performed through an incision in the skin near the anus. The injury to the anal sphincter is identified and the injured muscle edges are freed from surrounding scar tissue. The muscle edges are then brought back together using a series of stitches. The skin is closed with absorbable stitches which do not need to be removed. A small drainage tube is occasionally needed to prevent the accumulation of fluid around the sphincteroplasty, which is removed before you leave the hospital. Sphincteroplasty uses your own muscle, which is meant to control stool. Therefore, there is very little extra training needed to gain the benefit of stool control after this surgery. However, muscles may take several weeks or months to recover from the surgery. Kegel exercises or biofeedback to help retrain and strengthen the repaired muscle may be recommended after the sphincteroplasty has healed.

Artificial anal sphincter
The artificial anal sphincter is a totally implantable, simple-to-use device consisting of three components: 1) an inflatable cuff; 2) a fluid reservoir (balloon); and 3) a semi-automatic pump connected between the cuff and balloon. Fluid is placed within the balloon. The entire device is placed beneath the skin and is not visible at any time.

Two incisions are used to implant the device. One incision is placed between the anus and the vagina or scrotum. This incision is used to place the inflatable cuff around the anal sphincter. The second incision is placed in the lower part of the abdomen in the pubic region. This incision is used to make a space behind the pubic bone where the balloon is inserted. The pump is placed in a small pocket made beneath the skin of the labia or scrotum through the two existing incisions.

The artificial anal sphincter is not activated immediately. Six to eight weeks are allowed for healing from the surgery before the device is activated. Once activated, a few training sessions are usually necessary to learn how to use the device. Following activation, the anal cuff remains inflated in the “resting state.” This places pressure on the anal canal and keeps it closed, preventing the passage of stool. When the urge to have a bowel movement develops, the cuff is temporarily deflated by pressing the pump in the labia or scrotum several times. This moves the fluid from the cuff to the balloon and releases the pressure keeping the anus closed. The balloon automatically reinflates the cuff over the next several minutes. The only part of this process requiring any action is pressing the pump to deflate the cuff when the time for a bowel movement has arrived.

1. How is the anal sphincter damaged? Loss of anal sphincter function is due to either nerve or muscle damage. Nerve damage may result from trauma to the nerves (including spinal cord injuries) or medical conditions which affect nerve function (diabetes, multiple sclerosis). Muscular damage is often caused in women have had difficult vaginal deliveries (long labor, large baby, forceps or vacuum assistance, breech delivery, episiotomy or perineal tear). Surgical procedures on the anal canal for a variety of conditions (hemorrhoids, fissures, fistulas) may result in cutting of the anal sphincter muscle and incontinence. Accidents which result in injuries to the pelvis and anal area may also damage the anal sphincter muscle. Many years may pass between these injuries and the onset of incontinence.
    
2. Will I need a colostomy? A colostomy is rarely needed for the first attempt at sphincter repair or replacement, because infection and the passage of hard stool can be controlled through medication and diet. However, if a previous attempt has failed, a colostomy may be recommended.
    
3. What type of surgeon can perform the operation? Several types of surgeons, including gynecological, general and colorectal surgeons, can perform a sphincteroplasty. The most important factors to consider include a surgeon’s training in the procedure, number of procedures done (total and yearly) and results. In general, colorectal surgeons will have had the most formal training in the procedure and will frequently have the greatest experience in performing it.
   
   Very few surgeons are currently trained and approved to implant the artificial anal sphincter. The FDA has released this device on a Humanitarian Use Device Exemption. This allows the device to be used outside of a research study prior to full FDA approval. Strict requirements are placed on surgeons seeking approval to use this device, which we have met since 1999.
    
4. What are the results of sphincteroplasty? Results vary case to case, and often depend on the original cause of incontinence. Patients with normal nerves and an obvious injury to the sphincter muscle generally will have a better chance at success than patients with nerve damage or an unknown cause of incontinence. The range of success (good to excellent control of stool) is from 60 to 90 percent.
    
5. How effective is the artificial anal sphincter? The artificial anal sphincter is a simple, and highly successful method to improve stool control. Eighty to 90 percent of patients report improvement in control of stool and rate their control of stool as good to excellent. The improvement in control of gas is not quite as good as stool. The major concern with this device is infection which occurs in about 15 percent of patients and may require removal of the device. If this occurs, a new device may still be placed once the infection has cleared and the area has recovered from surgery. It is not yet clear how long each of the components of the device last and if replacement due to component failure will be required.
    
6. What if the sphincteroplasty and/or the artificial anal sphincter fails? Several options are available if a sphincteroplasty fails. If it is determined that the repair has fallen apart, a second sphincteroplasty can be attempted. The next option is the implantation of the artificial anal sphincter. Still other options are available, but these are much more involved to perform and have not shown better results than the artificial anal sphincter. These options include rotating muscle from the buttock (gluteus muscle transposition) or thigh (gracilis neosphincter) and wrapping it around the anal canal. A temporary colostomy is often necessary for a few months after a second operation on the anal sphincter. A colostomy is a good alternative to control stool when no other methods have been effective and the incontinence causes significant problems with work and/or social activities.