Anal incontinence: Strategic developments: Sacral nerve stimulation and soon Botox?
Seance of wednesday 14 may 2025 (Chirurgie proctologique)
DOI number : 10.26299/w2az-rc04/2025.18.03
Abstract
Anal incontinence (AI) is a prevalent condition, increasing significantly after the age of 65 and in individuals with underlying chronic intestinal disorders. However, epidemiological data indicate that 10–20% of adults aged 18 to 65 report at least one episode of fecal incontinence, with one-third experiencing recurrent episodes. Given its substantial impact on quality of life, routine screening for AI is warranted at all ages to facilitate timely initiation of appropriate treatment.
Management strategies are tailored according to the severity of symptoms and functional impact, which should be assessed at initial evaluation. Conservative treatment remains the first-line approach, incorporating dietary and lifestyle modifications, targeted pelvic floor rehabilitation, and pharmacologic agents to optimize bowel transit. Intervention therapies may be indicated in patients with persistent symptoms. Sacral nerve stimulation, used for over two decades, involves an initial 2- to 3-week trial period, during which efficacy is assessed before proceeding to permanent device implantation under sedation. Large cohorts report a definitive implantation rate of 60–65%, with significant improvements in fecal incontinence scores maintained for up to 10 years post-implantation. Intrarectal injection of botulinum toxin represents a more recent therapeutic option, primarily indicated for patients with urge-predominant AI. A recent clinical trial has demonstrated a statistically significant reduction in daily fecal incontinence episodes compared to placebo at 6 months.
In conclusion, AI management encompasses a spectrum of effective, minimally to moderately invasive therapies. Further research into predictive factors for therapeutic response is essential to optimize patient selection and improve clinical outcomes.
Management strategies are tailored according to the severity of symptoms and functional impact, which should be assessed at initial evaluation. Conservative treatment remains the first-line approach, incorporating dietary and lifestyle modifications, targeted pelvic floor rehabilitation, and pharmacologic agents to optimize bowel transit. Intervention therapies may be indicated in patients with persistent symptoms. Sacral nerve stimulation, used for over two decades, involves an initial 2- to 3-week trial period, during which efficacy is assessed before proceeding to permanent device implantation under sedation. Large cohorts report a definitive implantation rate of 60–65%, with significant improvements in fecal incontinence scores maintained for up to 10 years post-implantation. Intrarectal injection of botulinum toxin represents a more recent therapeutic option, primarily indicated for patients with urge-predominant AI. A recent clinical trial has demonstrated a statistically significant reduction in daily fecal incontinence episodes compared to placebo at 6 months.
In conclusion, AI management encompasses a spectrum of effective, minimally to moderately invasive therapies. Further research into predictive factors for therapeutic response is essential to optimize patient selection and improve clinical outcomes.