[Surgical therapy of fecal incontinence]

The algorithm of the treatment of the stool-incontinence starts with the differentiation between soiling and incontinence for flatus, liquid or formed faeces. In case of soiling, first all the causes that can be surgically solved should be treated. If this is not successful, the scheme of the incontinence-treatment should be followed. The first step is a dietary consultation, which includes prescription of appropriate drugs against diarrhoea, constipation and proctitis. The anal-physiological examinations will inform about the elasticity of the ampulla recti, which can be reduced in inflammatory processes, it will as well inform about the innervations of the ano-rectum and allow an objective sphincter pressure. If dietary therapy and drugs intake fail, the anal sphincter should be more closely examined. An endosonography or a perineal sonography and in case of a rectocele with incontinence a defecography need to be performed. In case of intact or defective sphincter a biofeedback training is started. If this is not successful, a sphincter-repair is performed in case of defective sphincter. To maintain the result the biofeedback training is continued. In case of failure as well as in case of intact sphincter that cannot be treated with the help of the biofeedback training, sacral nerve stimulation is indicated. If this does not work, the next step will be a dynamic graciloplasty or an artificial bowel sphincter. Both these methods are also indicated when the sphincter is missing. If this fails an anus praeter would definitively improve the quality of life of the patients. With bedridden or heavy demented patients, the anus praeter is often the first choice of procedure. The costs of the expensive pacemaker of the sacral nerve stimulation or the dynamic graciloplasty as well as the artificial bowel sphincter scare the insurances. Talking about cost and benefit these appliances are interesting as already in two years the costs a permanent anus praeter is causing are higher than the price of these medical appliances. In this overview article, different surgical procedures are described considering their indications, results and operative principles. The step-by-step use of the proposed algorithm leads to an optimal treatment of the stool-incontinence.