Use of Sacral Nerve Stimulation for the Treatment of Overlapping Constipation and Fecal Incontinence

Abstract

BACKGROUND Fecal incontinence and constipation are common gastrointestinal complaints, but rarely occur concurrently. Management of these seemingly paradoxical processes is challenging, as treatment of one symptom may exacerbate the other. CASE REPORT A 51-year-old female with lifelong neurogenic bladder secondary to spina bifida occulta presented with progressive symptoms of daily urge fecal incontinence as well as hard bowel movements associated with straining and a sensation of incomplete evacuation requiring manual disimpaction. Pelvic floor testing showed poor ability to squeeze the anal sphincter, which indicated sphincter weakness as a major contributor to her fecal incontinence symptoms. Additionally, on defecography she was unable to widen her posterior anorectal angle or relax the anal sphincter during defecation consistent with dyssynergic defecation. A sacral nerve stimulator was placed for management of her fecal incontinence. Interestingly, her constipation also dramatically improved with sacral neuromodulation. CONCLUSIONS This unique case highlights the emerging role of sacral nerve stimulation in the treatment of complex pelvic floor dysfunction with improvement in symptoms beyond fecal incontinence in a patient with dyssynergic-type constipation.

Figure 1.

Resting and squeeze: defecography and ARM showing complementary findings of normal sphincter integrity and resting tone, suggestive of intact internal anal sphincter function. Additionally, during voluntary squeeze there was inability to contract the sphincter or augment sphincter pressure suggestive of external anal sphincter weakness.

Figure 2.

Bearing Down: no significant evacuation of contrast or opening of anorectal angle on defecography. On ARM, there was no increase in rectal pressure, nor was there relaxation of the anal sphincter as compared to resting.