Sacral nerve stimulation for faecal incontinence

# Guidance
This document replaces previous guidance on sacral nerve stimulation for faecal incontinence (interventional procedure guidance 5).
Current evidence on the safety and efficacy of sacral nerve stimulation for faecal incontinence appears adequate to support the use of this procedure, provided that the normal arrangements are in place for consent, audit and clinical governance.
The procedure should only be performed in specialist units by clinicians with a particular interest in the assessment and treatment of faecal incontinence.# The procedure

# Indications
Faecal incontinence occurs when a person loses control of their bowel and is unable to retain faeces in the rectum. Faecal incontinence may result from dysfunction of the anal sphincter, which may be due to sphincter damage, spinal injury or a neurological disorder.
Faecal incontinence is associated with a high level of physical and social disability.
Typically, first-line treatment for faecal incontinence is conservative, such as anti-diarrhoeal medication and pelvic floor muscle training (including biofeedback therapy). In patients for whom conservative treatments have been unsuccessful, surgical alternatives include tightening the sphincter (overlapping sphincteroplasty), creating a new sphincter from the patient's own muscle (for example, dynamic graciloplasty) or implanting an artificial sphincter. Some patients may require colostomy. Sacral nerve stimulation is a surgical treatment option for patients with faecal incontinence.

# Outline of the procedure
In patients with a weak but structurally intact sphincter, it may be possible to alter sphincter and bowel behaviour using the surrounding nerves and muscles. It involves applying an electric current to one of the sacral nerves via an electrode placed through the corresponding sacral foramen. Commonly, the procedure is tested in each patient over a 2- to 3-week period, with a temporary percutaneous peripheral nerve electrode attached to an external stimulator. If significant benefit is achieved, then the permanent implantable pulse generator can be implanted.

# Efficacy
This procedure was subject to a systematic review commissioned by the Institute. The systematic review included six case series studies reporting on 266 patients in total. In patients who had permanent implants, complete continence was achieved in 4175% (19/4612/16) of patients, whereas 75100% (3/416/16) of patients experienced a decrease of 50% or more in the number of incontinence episodes. There was also evidence to suggest an improvement in the ability to defer defecation after permanent implantation. Patients also reported improvements in both disease-specific and general quality-of-life scores after the procedure. For more details, refer to the Sources of evidence section.

# Safety
Complications were reported both during the test peripheral nerve evaluation phase and after implantation. Evidence from the systematic review indicated that of the 266 patients receiving test evaluation, 4% (10/266) experienced an adverse event. Fifty-six per cent (149/266) went on to receive permanent implantation. Of the patients who had permanent implants, 13% (19/149) reported adverse events. These included three patients who developed infections requiring device removal, seven patients who had lead migration requiring either relocation (five cases) or removal of the device, and six patients who experienced pain after implantation.
Implantation techniques have been modified in recent years, with a view to reducing the occurrence of complications.
Andrew DillonChief ExecutiveNovember 2004# Further information

# Sources of evidence
The evidence considered by the Interventional Procedures Advisory Committee is described in the following document.
Fraser C, Glazener C, Grant A et al. Systematic review of the efficacy and safety of sacral nerve stimulation for faecal incontinence. Aberdeen: Review Body for Interventional Procedures; 2004. Commissioned by the National Institute for Clinical Excellence.

# Information for patients
NICE has produced information on this procedure for patients and carers ('Understanding NICE guidance'). It explains the nature of the procedure and the guidance issued by NICE, and has been written with patient consent in mind.# About this guidance
NICE interventional procedure guidance makes recommendations on the safety and efficacy of the procedure. It does not cover whether or not the NHS should fund a procedure. Funding decisions are taken by local NHS bodies after considering the clinical effectiveness of the procedure and whether it represents value for money for the NHS. It is for healthcare professionals and people using the NHS in England, Wales, Scotland and Northern Ireland, and is endorsed by Healthcare Improvement Scotland for implementation by NHSScotland.
This guidance was developed using the NICE interventional procedure guidance process.
It updates and replaces NICE interventional procedure guidance 5.
We have produced a summary of this guidance for patients and carers. Information about the evidence it is based on is also available.
Changes since publication
January 2012: minor maintenance.
Your responsibility
This guidance represents the views of NICE and was arrived at after careful consideration of the available evidence. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. This guidance does not, however, override the individual responsibility of healthcare professionals to make appropriate decisions in the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties.
Copyright
 National Institute for Health and Clinical Excellence 2004. All rights reserved. NICE copyright material can be downloaded for private research and study, and may be reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the written permission of NICE.
Contact NICE
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