An effective treatment for anal incontinence

Combination therapy for fecal incontinence is more effective than the current standard treatment. This is the conclusion of a randomized trial comparing the different treatments, described by Thilo Schwandner and colleagues in the current issue of Deutsches Ärzteblatt International (Dtsch Arztebl Int 2011; 108[39]: 653-60).

In Germany, 1-2% of the population suffers from anal incontinence. The problem is often caused by weakness of the pelvic floor muscles. Targeted training, biofeedback, and electrical stimulation are used to restore coordination to the muscles responsible for continence. For anatomical reasons, physical exercises alone do not suffice to train all of the relevant muscles; thus, stimulation with an electric current plays an important role as well.

The standard treatment to date, low-frequency electric stimulation, is painful for patients and is shown in the present study to yield no demonstrable therapeutic benefit.

In contrast, the combination therapy devised by the authors, which they call "triple-target treatment" (3T), restored continence in 50% of the patients who received it. In one component of 3T, the phasic voluntary musculature is trained with EMG-biofeedback so that patients can learn to activate the correct muscle groups to achieve continence. In a separate component, the smooth muscle (which cannot be voluntarily contracted) is treated with medium-frequency stimulation, which is less painful than low-frequency stimulation.

Anal incontinence remains a major clinical challenge because it markedly impairs patients' quality of life and because the available treatments to date have not been adequately effective. Currently, the treatment of anal incontinence generally begins with the elimination of individual factors that promote incontinence, involving, for example, bowel habits and food and fluid intake. Liquid stools are made more regular with solidifying fiber supplements or medications, while excess pressure on the bladder and bowel is avoided through changes in the patient's everyday behavior. If these measures do not succeed in cases of chronic anal incontinence, the recommended next step usually consists of nonsurgical methods such as pelvic floor exercises, biofeedback (EMG-BF), and electrical stimulation, with the purpose of bolstering the strength and coordination of the sphincter muscles.

Surgery is the first line of treatment for acute sphincter injuries.

In Germany, the Medical Aids Directory (Hilfsmittelverzeichnis, HMV) regulates the ordering of biofeedback and electrical stimulation and its reimbursement
by the statutory health insurance companies. Reimbursability is predicated on the demonstration of efficacy and cost-effectiveness; level I evidence is usually required for the reimbursement of active medical products. Although the categories of EMG-BF and lowfrequency electrical stimulation (LFS) have been included in the HMV as prescribable and reimbursable interventions for a number of years, their efficacy has never been adequately demonstrated. In multiple systematic reviews, it has been found that the flawed methods of the available clinical trials made it impossible to arrive at any definitive judgment about efficacy. Poor compliance also affects the effectiveness of LFS.