Anal Sphincter Repair for Traumatic Fecal Incontinence

Indications and Patient Selection

The American Gastroenterological Association recommends anal sphincteroplasty primarily for women with postpartum fecal incontinence and recent or acute sphincter injuries, but only after conservative therapy and biofeedback have failed for at least 3 months 1, 2, 3
Postpartum women with documented sphincter defects causing fecal incontinence who have failed conservative management are indicated for sphincter repair 1, 2
Recent or acute traumatic sphincter injuries with identifiable structural defects are also indicated for sphincter repair 1
Patients unresponsive to 3+ months of biofeedback therapy with evidence of sphincter damage on imaging or manometry may be considered for sphincteroplasty 3
The presence of a documented structural sphincter defect on endoanal ultrasound or MRI is a key selection criterion for sphincter repair, although this fact is not exclusively supported by cited references, a similar criterion of failure of conservative measures which benefit only ~25% of patients is supported 3
The American College of Gastroenterology suggests that the absence of severe pudendal neuropathy is a favorable factor for sphincter repair 1

The treatment algorithm for fecal incontinence involves a stepwise approach, starting with conservative management, followed by biofeedback therapy, and finally sphincteroplasty if previous steps fail 3
Conservative management includes diet modification, fluid management, and bowel training, with an expected success rate of ~25% 3
Biofeedback therapy involves pelvic floor retraining with biofeedback for patients not responding to conservative measures, with a minimum 3-month trial before declaring failure 3
Sphincteroplasty is reserved for patients who fail Steps 1 and 2 with documented sphincter defects 3

The preferred approach for sphincter repair is the overlapping sphincteroplasty technique, which shows lower fecal urgency and better anal incontinence scores at 1 year compared to end-to-end repair 4
The surgical technique involves sequential repair from deep to superficial, including anorectal mucosa, internal anal sphincter, external anal sphincter, rectovaginal fascia, and perineal body 4
Preoperative antibiotics are mandatory to reduce wound infection rates 4
Postoperative care involves Foley catheter placement, pain control with local cool packs, topical anesthetics, acetaminophen, and NSAIDs, and avoidance of opiates when possible 4

The success rate of sphincteroplasty deteriorates significantly over time, with only 28% of patients continent at 40 months in some series 1, 2
The median time to relapse after sphincteroplasty is 5 years 1, 2
Wound complications, including infection and dehiscence, can occur, but are reduced with prophylactic antibiotics 1, 2, 4
The American Society of Colon and Rectal Surgeons notes that newer minimally invasive modalities, such as sacral nerve stimulation and bulking agents, may soon be considered first-line surgical approaches for fecal incontinence, except in patients with recent/acute sphincter injuries 1, 2