Faecal incontinence can be a highly distressing and socially embarrassing problem. People suffering from this problem can’t control their stools and have bowel “accidents” if they are not able to get to the toilet in time.

Treatment for faecal incontinence ranges from something as simple as a change of diet and medication, to specialised exercise regimes that strengthen the pelvic floor – the muscles that support the organs in the abdomen.

Procedures to repair damaged muscles around the anal area, if they are torn, and surgery to stimulate the spinal nerves to improve muscle function are other options.

At Singapore General Hospital (SGH), a member of the SingHealth group, a new procedure known as the GateKeeper has been available for some patients with faecal incontinence since January 2012, marking the first time the procedure has been performed outside continental Europe.

“For patients whose faecal incontinence is mild but who have not responded to conservative treatment measures such as dietary changes, medication or exercise, injecting a special bulking agent into the anal area can help to bolster the native tissues. This improves the seal of the anal canal and reduces accidental leakage of stool,” said Dr Mark Wong, Consultant Surgeon, Department of Colorectal Surgery and Director, Pelvic Floor Disorders Service, Singapore General Hospital (SGH), a member of the SingHealth group.

"Injectable bulking agents are generally safe with few adverse effects. But long-term efficacy can be an issue depending on the material used and technique of implantation", said Dr Wong. The GateKeeper procedure uses a bulking agent made from a material known as polyacrylonitrile, which is able to change its shape and volume once it is in contact with human tissue. It thickens after 24 hours.

“It is not biodegradable and potentially lasts longer,” said Dr Wong, who performed the first two procedures in Asia.

The half-hour procedure, which implants a bulking material into the muscles around the anal canal, can be performed under local anaesthesia, making it relatively safe and fast. During the procedure, six 2mm cuts are made around the anal opening. Guided by 3-D ultrasound, the bulking agent is implanted with precision through the small incisions using a customised handheld device. The incisions are then stitched shut.

The material then changes its shape and expands in volume by up to 720 per cent, augmenting the natural anal canal to encourage a better seal. This lets the patient have more control over his bowel movements and reduces the severity of incontinence, said Dr Wong.

Treating faecal incontinence with the GateKeeper procedure

The GateKeeper procedure was developed in 2005 by Professor Carlo Ratto, a colorectal surgeon from the Catholic University of Rome, Italy. He monitored the progress of 14 patients who underwent the GateKeeper procedure and published the findings in the British Journal of Surgery in 2011.

The patients did not suffer any complications. After about 33 months of observation, Dr Ratto found that the severity and frequency of faecal incontinence had decreased, and the patients could control their bowels much better. Commenting on Professor Ratto’s findings, Dr Wong said: “Despite the small number of patients, the results are impressive because most studies on other injectable agents have shown promising results for up to only one year, with a loss of durability thereafter.” He added that the GateKeeper procedure is probably suitable for about 10 to 20 per cent of patients with faecal incontinence.

To be considered for the procedure, patients have to be suffering from mild faecal incontinence for at least six months. Patients must also have undergone at least six months of continued conservative treatment, which includes dietary changes, medication and pelvic floor exercises without signs of improvement, said Dr Wong.

The procedure isn’t for patients who are at high risk of post-operative complications, including those with anal infections, poorly controlled diabetes or inflammatory bowel disease (IBS). Those undergoing treatment for colorectal cancer are also not suitable. Those with severe faecal incontinence, as a result of nerve damage or with significant loss of soft tissue around the anus, are also less likely to benefit from this procedure.

As with any surgical intervention, the GateKeeper procedure comes with a small risk of complications, such as infection, pain or an allergic reaction to the implant material. Although rare, bleeding and pain can also arise if the implant erodes over time.

But these problems are rarely life threatening, which makes the procedure relatively safe for most patients, said Dr Wong.

Faecal incontinence: causes, symptoms and treatment

What is faecal incontinence?

It causes involuntary bowel movements, ranging from an occasional leakage of gas, to loss of control over solid stool.

What causes it?

Ageing and childbirth are the two primary risk factors. Other factors include anus, rectum or colon surgery, radiotherapy applied to the pelvic organs, medical conditions like diabetes and stroke, and trauma to the spine or pelvis. Women are at a higher risk if they have delivered children naturally.

Treatment for mild symptoms

Dietary changes and anti-diarrhoea medication can improve stool consistency and increase its bulk, while pelvic-floor exercises can boost coordination of the muscles that control bowel movements.

Treatment for severe symptoms

If the muscle around the anus, known as the anal sphincter, is damaged, it may be surgically replaced with an artificial one. In extreme cases, a colostomy may be performed: Stool is diverted through an opening in the abdomen and into a special bag that collects the stool.


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