Sacral Nerve Stimulation for Fecal Incontinence

Fecal incontinence, when you unintentionally find yourself passing stool, can be an extremely upsetting experience. When it happens on an ongoing basis it can take quite a toll on a person's quality of life, social life, and sex life. People who experience incontinence on a regular basis frequently struggle with emotions of deep shame, understandable anxiety about future accidents, and low self-esteem.

Fecal incontinence is a surprisingly common condition, affecting approximately 5 to 15% of people (those who actually report the problem!) and up to 50% of adults living in nursing homes. If you yourself are experiencing bathroom accidents, please don't be too embarrassed to speak to your healthcare provider about it. Your practitioner is sure to be non-judgmental and supportive, and you will be relieved to learn that there are many options for addressing the problem. One such option, for situations in which standard protocols for treatment are not enough, is the use of sacral nerve stimulation.

Sacral Nerve Stimulation

Sacral nerve stimulation, otherwise known as sacral neuromodulation, is a medical intervention that was first designed as a treatment for bladder accidents. The treatment involves the insertion of electrodes into the area where your sacral nerves are located. These electrodes are contained in thin, flexible wires that are inserted under your skin in the area of your lower back near your tailbone. These wires are then connected to a device that sends low-level electric pulses to stimulate these nerves.

The original thinking behind this treatment is that the stimulation of these particular nerves will improve the functioning of your anal sphincter and the muscles within your pelvic floor. The use of the device was approved as a treatment for fecal incontinence by the U.S. Food and Drug Administration in 2011.

The treatment is actually a two-step process. For the first step, the leads are placed inside your body, but the stimulating device remains outside of your body with a small device taped to your waist. This procedure typically takes place using local anesthesia. You will then be asked to keep a symptom diary for approximately two to three weeks. Your healthcare provider will then work to adjust the device to try to optimize it to the needs of your body. Your practitioner may advise you to restrict some of your activities through this trial period.

At the end of this first phase, if you are receiving benefit from the treatment and the unit is attuned to your body, a second procedure will be performed to implant the device under your skin in the area of your abdomen. The under-the-skin implantation procedure will only be performed on you if your soiling accidents have been reduced by half with the use of the device. The implanted device can continue to be adjusted using an external remote control device.

Who Is a Candidate?

Sacral nerve stimulation will not be considered until conventional treatment options have been attempted. If adequate relief of symptoms has not been achieved after trying dietary and behavioral changes and less invasive techniques, sacral nerve stimulation may be recommended. The treatment appears to be helpful for people who have either passive incontinence (involuntary leakage) and urge incontinence (not getting to the bathroom on time). The treatment can be helpful for fecal incontinence that comes from a wide variety of causes, such as:

• Following childbirth: anal sphincter tears or nerve damage
• Neurological problems
• Of unknown origin (idiopathic fecal incontinence)

There is also some research support that sacral nerve stimulation can be helpful if you are dealing with both bladder and fecal incontinence at the same time.

How Sacral Nerve Stimulation Works

What is unknown is exactly what sacral nerve stimulation does that improves an incontinence problem. Several theories are being explored. Although common sense would suggest that the nerve stimulation is improving the functioning of the pelvic floor and anal sphincter muscles, research is not necessarily providing overwhelming evidence of this. Another theory is that the stimulation is improving the muscle action of the entire colon. There is also some evidence that the treatment effects changes in the parts of the brain that control continence.

How Helpful It?

In general, sacral nerve stimulation is seen as an effective, minimally invasive treatment option. Having it as an option has reduced the rates of surgery to repair the anal sphincter. Initial effects can be quite impressive, with research indicating a significant reduction in symptoms being experienced by 40 to 80% of people who have the procedure. These results typically stay strong for at least one year. Studies have shown that up to 80% of people who undergo the procedure are quite pleased with the results and report that the treatment has increased their quality of life. Approximately 25% of people who have the device may see a slight decline in symptom improvement over time. The biggest downside to the procedure is the possible need for repeat surgical procedures.

Side Effects

The procedure itself carries minimal risks. However, because it is a surgical procedure there is the slight risk of infection. Of greater concern is that you do need to be aware of the possible need for further surgeries. The device may experience technical problems that could involve replacement. This rate of further surgeries is not insignificant, with research indicating that it may be required for one out of every five people who have the device. The risk of needing the device to be re-implanted does increase over time.

What to Expect When Living With the Stimulating Device

In a best-case scenario, living with the device means that you will be free to live your life without worrying about experiencing soiling accidents. You will be instructed as to how to temporarily "turn off" the electrical pulses when you are ready to experience a bowel movement. If the device is set too high, you may experience slight shocks. If the device is set too low, you may not be receiving full benefits. For the best results, you will keep in touch with your healthcare provider to ensure that the settings are optimal for you.

Alternative Treatments

Although sacral nerve stimulation is considered standard care for treatment of moderate to severe fecal incontinence, it is not the only option available. Here are some examples of some of the other things that your healthcare provider may recommend to you:

1. Avoiding foods and drinks that can raise your risk of an accident. This would include alcoholic drinks, drinks with caffeine, spicy foods, and excessive amounts of fruit.
2.  Increasing your intake of dietary fiber. Dietary fiber can help to keep stools firm, which helps your body to retain fecal matter until you are comfortably seated at a toilet. Dietary fiber can also help to keep stools soft, thus encouraging movements for people who are constipated and therefore reducing the experience of stool leaking out around impacted stool.
3. Your healthcare provider may recommend that you use a fiber supplement such as Metamucil to improve stool consistency and promote regular bowel movements.
4. Your healthcare provider may recommend the use of an anti-diarrheal medication such as Imodium.
5. Medications may be prescribed to address any underlying conditions that are resulting in your incontinence.
6. If fecal impaction is a chronic problem (particularly for elderly individuals living in nursing homes), a treatment regimen that includes the use of suppositories, enemas and/or oral laxatives may be recommended.
7. There is an injectable gel called Solesta which increases the size of anal tissue. This creates a narrower opening which improves your ability to retain stool.
8. There are a few other non-invasive treatments that can target and improve the symptoms of fecal incontinence. These include:
9. Biofeedback
10. Pelvic floor exercises (Kegels)
11. Electrostimulation