Fecal incontinence is a prevalent and frustrating problem that has a profound impact on physical and psychological well-being. Appropriate care relies on systematic evaluation and application of a tailored treatment plan. Figure 88-3 presents a systematic algorithm for care of patients with persistent fecal incontinence. Although we champion the methodical approach, we frequently encourage a combined treatment plan, such as medical optimization, biofeedback, and sphincteroplasty, depending on the needs and abilities of individual patients. Broad adaptation of a standardized pre- and postintervention evaluation system will enhance the individual patient's experience and our understanding of treatment effectiveness.

Anorectal physiology tests Endoanal ultrasonography Fecal incontinence measuring tool

Primary etiology = Neurologic defect (eg, pudendal nerve palsy or systemic peripheral neuropathy)

Primary etiology = Anatomic defect (eg, anal sphincter disruption)

Biofeedback training1

Overlapping sphincteroplasty1*

Sacral nerve stimulation2!"

Artifical bowel sphincter2

Dynamic graciloplasty2*

End stoma3

Secca procedure§

Anal plug device§

Anal canal bulking agent§

FIGURE 88-3 An evaluation and treatment algorithm for fecal incontinence. 11ndicates first line therapy, with conservative management as above. *Failed sphincteroplasty should be re-evaluated. Good results may still be achieved with a re-wrap or with biofeedback therapy. 2Second line therapy. ^Available on protocol only. fNot available in the United States. 3Permanent stoma represents a definitive therapy option for many patients, especially those with reduced medical access, limited mobility, or impaired cognitive or psychological function. §Available off protocol but limited efficacy data available at this time.

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