VM102 - Overlapping Sphincteroplasty for Fecal Incontinence

Purpose/Background: Fecal incontinence (FI) is defined as acquired loss of control of the passage of feces or gas.1 FI can result from multiple etiologies such as anatomic abnormalities, neurologic issues, rectal dysfunction, or a combination of the above.2 For postpartum women, obstetric injury is a common cause of FI and can be associated with rectovaginal fistula.3 Initial evaluation involves a thorough history and physical exam and can include adjuncts like anorectal manometry, ultrasound, defecography. If first-line conservative therapy such as dietary modification, stool bulking agents, and biofeedback fail, surgical intervention may be indicated.4 Surgical management of FI includes sacral neuromodulation, injection of bulking agents, or sphincteroplasty.1

This is a case of a 26 year-old female with complaints of fecal leakage. She sustained a fourth-degree perineal laceration during vaginal delivery 6 months prior, which was immediately repaired. She subsequently experienced seepage of gas and stool per vagina and anus. On physical exam, she had thinning of the perineal body and rectovaginal septum. Endorectal ultrasound showed scarring and a sphincter defect of the anterior internal and external sphincters. Given her young age and concomitant rectovaginal fistula, we proceeded with overlapping sphincteroplasty with fistula repair.

Methods/Interventions: A transperineal sphincteroplasty was performed. Full mechanical bowel preparation and general anesthesia were utilized. The patient was placed in prone position. The rectovaginal fistula was identified and the rectovaginal septum was dissected out to identify and mobilize both stalks of the muscle complex on each side of the defect, and a vest-over-pants suture repair was performed. The septal space was obliterated using interrupted sutures, and a drain was placed post-operatively.

Results/Outcomes: Post-operatively, the patient did well with resolution of fecal seepage via vagina and anus.

Conclusion/Discussion: This case highlights the surgical pearls and efficacy of overlapping sphincteroplasty in treating acquired FI secondary to obstetric injury. Overlapping sphincteroplasty has been shown to have good results in 70% of patients in the first 3 months, and is a viable surgical option for young patients with fecal incontinence due to sphincter defects.5

Reference:

1Steele, Scott R., et al., eds. The ASCRS manual of colon and rectal surgery. Springer, 2019
2Bharucha, Adil E et al. “Faecal incontinence in adults.” Nature reviews. Disease primers vol. 8,1 53. 10 Aug. 2022, doi:10.1038/s41572-022-00381-7
3Sideris, Michail et al. “Risk of obstetric anal sphincter injuries (OASIS) and anal incontinence: A meta-analysis.” European journal of obstetrics, gynecology, and reproductive biology vol. 252 (2020): 303-312. doi:10.1016/j.ejogrb.2020.06.048
4Assmann, Sadé L et al. “Guideline for the diagnosis and treatment of Faecal Incontinence-A UEG/ESCP/ESNM/ESPCG collaboration.” United European gastroenterology journal vol. 10,3 (2022): 251-286. doi:10.1002/ueg2.12213
5Van Koughnett, Julie Ann M, and Steven D Wexner. “Current management of fecal incontinence: choosing amongst treatment options to optimize outcomes.” World journal of gastroenterology vol. 19,48 (2013): 9216-30. doi:10.3748/wjg.v19.i48.9216