SOften buried under the weight of embarrassment, fecal incontinence is a deeply disabling condition. To break down the wall of stigma, we interviewed the Dr. Paola De Nardi, president of the Italian Society of Colo-Rectal Surgery (SICCR)as well as Head of Functional Unit at the Colorectal Surgery Unit of the IRCCS San Raffaele Hospital, directed by Professor Pierpaolo Sileri. Together, they chair the 11th National Congress of the SICCR, which kicked off today.
Alarming data: the impact is greater than diabetes
A meta-analysis of 2023, conducted on 80 studies with 548,316 adults involved, revealed an incidence in the general population of approximately 8% (Mayo Clinic Proceedings), a percentage that rises in the elderly, with peaks of up to 15% in the over 80s. «But the numbers could be much higher – warns De Nardi – if we consider that this condition is often kept hidden, even from the treating doctor». In the elderly hospitalized in RSAs, the data reaches alarming peaks, reaching 45–50% of guests (BMJ Open2019).
Lesion of the sphincters
The causes can be different and in most cases they are combined. «The congenital forms are rather rare, being more often an acquired condition, mainly linked to a lesion of the anal sphincters (the circular muscles located around the anus) such as consequence of trauma or surgery”.
Childbirth injuries
«Obstetric injuries during childbirth are typical in women», continues the specialist. «The problem can appear immediately, often in a temporary form, with all the management difficulties associated with such a delicate moment. In some cases, it can manifest itself even years later, when other factors cause latent dysfunctions to emerge.”
Less common causes are neurological (stroke, spinal cord injury, advanced diabetic neuropathy) or linked to inflammatory bowel diseases (Crohn’s disease or ulcerative colitis).
Medical history is at the heart of the diagnosis of fecal incontinence
For diagnosis, it is essential to collect complete information from the patient and perform a thorough physical examination. Subsequent instrumental tests (endoanal ultrasound and anorectal manometry) serve to identify the origin and, therefore, intervene in a targeted manner.
Rehabilitation is the cornerstone of therapy
Treatment begins with a conservative approach, including lifestyle advice and the use of antidiarrheal medications and fiber. “The cornerstone of the therapy is the rehabilitation of the pelvic floor, which in many cases can resolve the problem on its own.” It includes various techniques, from physiotherapy to biofeedback, which adopts visual or auditory stimuli, to electrostimulation with targeted electrical impulses, up to percutaneous stimulation of the tibial nerve, which uses indirect nervous reflexes.
Traditional surgery
When conservative treatment is not sufficient, surgery can be resorted to, reconstructing the damaged sphincters with sphincteroplasty.
Minimally invasive surgery
Sacral neuromodulation is a minimally invasive technique that involves the implantation of a stimulator that sends continuous electrical impulses to the sacral roots. Initially reserved for cases of unknown origin, it is now indicated in the guidelines as the first surgical step.
Another option is local injections of volumizing agents, such as hyaluronic acid, autologous fat or other biocompatible substances.
Transanal irrigation techniques
They consist of intestinal washes at controlled pressure, performed by the patient at home every 2-3 days, to empty the left side of the colon. “Studies conducted in the last decade have demonstrated excellent results”, recalls the doctor, hoping for an ever greater diffusion.
The new frontier of regenerative medicine
THE’San Raffaele Hospital and the San Donato Polyclinic are the two IRCCS Italians involved in a international multicenter research projectconducted on approximately 250 patients suffering from emergency fecal incontinence. The aim of the phase 3 clinical study is to evaluate the safety and efficacy of the implantation of autologous cells derived from skeletal muscle, cultured from a small tissue sample and then reintroduced into the external anal sphincter to strengthen its function. Started about a year and a half ago, it will end in the next six months, with encouraging preliminary results.
Don’t hide the problem: solutions exist
«It is important to turn to centers with consolidated experience in the complete management of all problems of the colon and rectum. Even before that – concludes De Nardi – it is essential not to hide the problem, because therapeutic opportunities exist and offer good prospects, both for mild and chronic forms”.