Physiological Investigations

Loose Pelvic Floor Rectal Prolapse Gifs

The primary aims of tests used in FI patients are to better elucidate the pathophysiology and address the treatment. This is particularly complex, not only due to the lack of comprehensive knowledge on pelvic floor morphology and physiology but also because of the wide variety of tests used, not always as standard procedures. This assessment must concern both function mostly provided by anorectal manometry (ARM), rectal sensations investigation, and anorectal electrophysiology (AREP) and...

Patient Selection

Baseline evaluation of symptoms described by a patient presenting with FI is fundamental in order to establish severity of continence dysfunction and its impact on the patient's lifestyle. Usually, this can be derived from a clinical assessment (including clinical history and physical examination), as well as from the evaluation of a diary kept by the patient concerning normal bowel movements and episodes of FI, specifying which kind of material has been lost (gas, liquid, solid stool)....

Children with Constipation Colonic Hypomotility

In these children, colon motility is significantly reduced. The basis of the bowel management program in these patients is to teach parents to clean the child's colon once a day with a suppository, an enema, or colonic irrigation. No special diet or medications are necessary. The fact that these children suffer from constipation (hypomotility) is helpful, as it helps them remain clean between enemas. The real challenge is to find an enema capable of completely cleaning the colon. Definitive...

Diagnostic Tools Endoanal Ultrasound

Since the early 1990s, anal ultrasound has become an important tool in studying the anal sphincter complex. The technique's popularity began after a publication by Law and Bartram in 1989 18 . Ultrasound gained popularity in visualizing, defining, and describing the anatomy of the anal canal and the sphincter complex 19, 20 . The ultrasonographic findings were compared and correlated to elec-tromyography (EMG) and manometry. Law et al. 21 studied 15 patients with fecal incontinence due to...

Autonomic Nervous System Diabetes Mellitus

It is well recognised that lower gastrointestinal symptoms, including diarrhoea and incontinence, are frequently reported by patients with diabetes, more so than in the general population, although the patho-genesis is unclear. A prevalence of 7 among a cohort of 540 diabetics has been reported 38 , with some degree of symptom fluctuation (improvement in some, new onset in others) over time. Abnormal gastrointestinal sensorimotor function (including internal sphincter dysfunction 39 and blunted...

Parkinsons Disease and Parkinsonian Syndromes

The majority of patients with PD or parkinsonian syndromes-in particular, multiple system atrophy (MSA)-complains of gastrointestinal and pelvic organ dysfunction. Stocchi et al 26 reported a similar occurrence of altered bowel frequency and defecation in PD and MSA patients. Gastrointestinal symptoms in PD include gastroparesis and constipation as a result of decreased bowel movement frequency and defecation difficulty. In all patients, these disorders became manifest or worsened after the...

References

Johanson JF, Lafferty J (1996) Epidemiology of fecal incontinence the silent affliction. Am J Gastroenterol 91 33-36 2. Kok AL, Voorhorst FJ, Burger CW et al (1992) Urinary and fecal incontinence in community-residing elderly women. Age Ageing 21 211-215 3. Talley NJ, O'Keefe EA, Zinsmeister AR, Melton LJ 3rd (1992) Prevalence of gastrointestinal symptoms in the elderly a population-based study. Gastroenterology 102 895-901 4. Roberts RO, Jacobsen SJ, Reilly WT et al (1999) Prevalence of...

Internal Anal Sphincter Abnormalities

The majority of lesions of the IAS are due to iatro-genic and obstetric injuries, often in combination with injuries to the EAS, leading to faecal incontinence. Smaller lesions leading to minor faecal incontinence or soiling are due to hemorrhoidectomy or mucosal prolapsectomy. Manual anal dilatation 65 or lateral internal sphincterotomy 66-68 are notorious and have been associated with faecal incontinence in 27 and 50 of patients, respectively. Fistula surgery can cause faecal incontinence in...

Pathophysiology of Anorectal Dysfunction in Diabetes Effects of Autonomic Dysfunction and Hyperglycaemia

Many studies of anorectal function in diabetes have substantial limitations the techniques used were often suboptimal, only isolated aspects of anorectal function were evaluated, and no account was taken of the potential impact of acute or chronic glycaemia. A number of factors, including autonomic neuropathy, glycaemic control, and psychiatric comorbidity, may potentially influence the development and or regression of gastrointestinal symptoms, including incontinence, in diabetes. As...

Inspection

Medical Anus

Severe incontinence, particularly to liquid feces, can cause erosion and erythema of the perianal skin. Those lesions, as well as scratching erosions that may accompany them, can present signs of infection, frequently due to streptococcus and fungi. In that case, specimen cultures may be taken. Perineum inspection helps identify scarring from previous trauma, episiotomy, or anal surgery that may indicate the etiology of incontinence. External fistula-in-ano openings or inflammatory areas that...

Multiple Sclerosis Myelopathies and Spinal Cord Injury

Multiple sclerosis (MS) is a progressive neurologic disease that results from multiple demyelinating lesions within the CNS and that shows a variety of clinical presentations and courses determined by the location and number of the same lesions. Bladder and bowel dysfunction is the third most important discomfort in MS patients after spasticity and fatigue 33, 34 . Genitourinary dysfunctions in MS patients frequently occur due to the spinal involvement, with an incidence of 78 35-38 ....

Chronic Constipation

FI can occur in patients affected by chronic constipation as a consequence of stool retention in the rectum, resulting in overflow incontinence. Chronic fecal retention determines a significantly decreased anorectal sensation. On the other hand, constipation can be caused by excessive consumption of drugs, including antidiarrheals, narcotics, calcium-channel blockers, antidepressants, and other psychotropic agents. Finally, particularly in the older subjects, dehydration and insufficient fiber...

Fecal Incontinence in Peripheral Neuropathies

Many patients affected by idiopathic fecal incontinence have evidence of either a neurogenic or muscular injury, and some patients remain truly idio-pathic without clear identifiable cause for sphincteric dysfunction. The peripheral nervous system is divided into the somatic and autonomic portions with sensory and motor nerve fibers. Autonomic nerve fibers normally supply the gastrointestinal, bladder, sexual, and cardiovascular functions. Neuropathies can be functionally selective so that...

The Injectable Bulking Agents

In broad terms, an agent should be biocompatible, nonmigratory, nonallergic, nonimmunogenic, non-carcinogenic, easy to inject and able to produce durable results. Such an agent probably does not yet exist. Scientific studies have looked at particle size in relation to their potential for local and distant migration. It would appear that particles should be at least 80 mm in diameter to avoid phagocytosis and transport throughout the body. As with sacral nerve stimulation, there is no consistent...

Episiotomy

Episiotomy is a widely performed intervention in childbirth despite equivocal scientific evidence might regarding its benefit. Routine episiotomy avoid spontaneous uncontrolled tears and long-term relaxation of the pelvic floor, but these advantages are difficult to substantiate. There is a widespread assumption that it may do more harm than good 43 . In fact, there is no evidence that either first- or second-degree perineal tears cause long-term consequences 44 . Moreover, a growing body of...

Rectal Evacuatory Disorder

Faecal impaction is an important risk factor for incontinence and predominantly affects older people, especially those living in institutions 41,95 , but also children 25, 41, 145 . In the elderly, approximately 50 of nursing home residents will suffer from faecal incontinence 41, 233, 234 prolonged retention of stool in the rectum, perhaps secondary to incomplete evacuation during defecation but also as a consequence of other factors, such as physical immobility, inadequate diet and water...

Overflow Incontinence

Identification of fecal impaction with or without megarectum is of great importance, because remediation is available and highly effective 7, 19 . Disim-paction is the first step and often includes digital fracturing of the bolus. If the impaction is very hard, a 500- to 750-ml water enema with 1-2 tablespoons of mineral oil added can serve to soften the bolus to facilitate fragmentation and passage of the fecal bolus. Once the obstructive mass is removed, larger-volume warm-water enemas may be...

Neurophysiologic Investigations

Neurophysiological examination of patients with fecal incontinence usually follows surgical and clinical evaluation and, almost always, other endoscopic, manometric, ultrasound, and MRI investigations able to diagnose the most important causes of fecal incontinence 98 . These different investigations can identify focal morphological lesions to the IAS and EAS muscle 99-101 , location of neoplastic lesions 102 , capacity and compliance of the rectum, reflex activity, reduced sensation of the...

Suprasphincteric Dysfunction

Stool Consistency Volume and Gastrointestinal Transit The consistency of the faeces and the rate at which they are introduced into the rectum may play a role in determining incontinence. Liquid stools rapidly delivered to the rectum are able to determine urgency and incontinence even in normal subjects 6 . Many patients with idiopathic FI have chronic diarrhoea, often secondary to irritable bowel syndrome (IBS). In these subjects, sigmoid pressures and sigmoid motility index are usually higher...

Proctological Procedures General Introduction

Fecal Incontinence

Studies often underestimate iatrogenic incontinence, as follow-up is often short and trials are powered to show difference in intervention efficacy, not effect on continence. Anal-canal pressures decrease with age, and the initial iatrogenic injury may be compounded by subsequent obstetric injury 1 . Therefore, incontinence resulting from the proctological procedure may not be unmasked for a number of years. We recently published our experience of patients with incontinence after proctological...

Place of the ABS at the Time of the Sacral Nerve Stimulation SNS

Recently in a systematic review from Australia 13 , the role and place of the ABS have been challenged. On the basis of a full review of the literature, the authors concluded that there was insufficient evidence on the safety and effectiveness of ABS implantation and for most patients, the procedure was of uncertain benefit. Such a statement is clearly not reflective of our practice, even if we agree on the exigence of ABS therapy for patients and surgical teams. In the mean time, others have...

Repair of Third and Fourthdegree Perineal Lacerations Introduction

Data from the obstetrical literature show that about 0.4-3.7 of all vaginal deliveries result in a third- or fourth-degree perineal laceration 1, 2 . Rarely, the reported incidence can go as high as 20-39 3, 4 . When a third- or fourth-degree perineal laceration occurs during vaginal delivery, the standard repair is to approximate the torn ends of the anal sphincter using two to six interrupted mattress or figure-of-eight stitches and close the vaginal and perineal tissues in layers....

Lateral Internal Anal Sphincterotomy

Internal sphincterotomy was introduced into surgical practice more than 50 years ago 169 , with the lateral subcutaneous sphincterotomy becoming the procedure of choice after it was first reported by Notaras in 1969 170 . This represents a controlled division of the internal anal sphincter in its caudal part, usually to the dentate line. Although lateral internal sphincterotomy remains the surgical treatment of choice for chronic anal fissures unresponsive to medical therapy, with healing rates...

Anal Sphincter Tone and Reflexes Internal Anal Sphincter

The internal sphincter is primarily responsible for ensuring that the anal canal is closed at rest 14, 38 . The other contributors to anal resting tone include the external anal sphincter, the anal mucosal folds, and the puborectalis muscle. Penninckx et al. 39 estimated that anal resting tone was generated by nerve-induced activity in the internal sphincter 45 of anal resting tone , myogenic tone in the internal sphincter 10 , the external sphincter 35 , and the anal hemorrhoidal plexus 15 ....

Internal Anal Sphincter

As all fourth-degree perineal lacerations and a significant number of third-degree tears involved the internal anal sphincter, some investigators have proposed that obstetricians should specifically look for, and repair when present, a torn internal sphincter. The function of the internal anal sphincter is to maintain a constant tone in the anal canal, and repairing it would theoretically reduce the risk of developing passive incontinence. Two British investigators attempted to identify and...

Rectal Sensitivity

Rectal hyposensitivity RH has been reported in patients with fecal incontinence. This is best doc umented in patients with diabetes mellitus 64 and multiple sclerosis 32 but has also been seen in patients with idiopathic fecal incontinence 65-69 . Rectal balloon distention with either air or water can be used for the assessment of both sensory responses and compliance of the rectal wall. By distending a rectal balloon with incremental volumes, it is possible to assess the thresholds for three...

Childbirth after a Thirddegree Tear

Third- and fourth-degree perineal lacerations occur three to seven times more frequently among nulli-paras than multiparas 27, 38, 39 . Consequently, many women who had an anal sphincter tear would want to have more children. Vaginal delivery after an anal sphincter tear has frequently been cited as a major risk factor for developing a new and more severe anal incontinence 8,14, 21, 38 . As we do not know how to effectively repair a torn anal sphincter, and a significant number of failed...

Surgical Treatment Sphincter Repair

There are three methods of repairing the sphincter apposition, plication reefing, and overlapping sphincteroplasty 37 . Apposition has classically been associated with low success rates 91 . Scar tissue Table 1. Cleveland Clinic Florida Fecal Incontinence CCF-FI scorea. From 37 Table 1. Cleveland Clinic Florida Fecal Incontinence CCF-FI scorea. From 37 a0 perfect continence, 20 complete incontinence a0 perfect continence, 20 complete incontinence Table 2. Influence of pudendal neuropathy on...

Balloon Expulsion Test

A balloon expulsion test can identify impaired evacuation in patients with fecal seepage or in those with fecal impaction and overflow. Most normal subjects can expel a balloon containing 50 ml water 56 or a silicon-filled artificial stool from the rectum in less than a minute 79 . In general, most patients with fecal incontinence have little or no difficulty with evacuation. But patients with fecal seepage 46, 50 and many elderly subjects with fecal incontinence secondary to fecal impaction...

Pseudoincontinence

It is vital to differentiate real fecal incontinence from overflow pseudoincontinence. As in patients with real fecal incontinence, the normal bowel control mechanism is deficient. Pseudoincontinence occurs when a patient behaves as if they are fecally incontinent, but they really have severe constipation and overflow soiling. Once the disimpaction is treated and the patient receives enough laxatives to avoid constipation, he or she becomes continent. The colon absorbs water from the stool and...