Nerve Supply to the Pelvic Floor Autonomic Innervation

The anorectum and pelvic floor are supplied by sympathetic, parasympathetic, and somatic fibers 13 . Sympathetic pre ganglionic fibers originate from the lowest thoracic ganglion in the paravertebral sympathetic chain and join branches from the aortic plexus to form the superior hypogastric plexus. Because the superior hypogastric plexus is not a single nerve, the alternative term for this plexus, i.e., presacral nerve, should be avoided. The superior hypogastric plexus provides branches to the...

Invited Commentary

Anal endosonography has revolutionized the treatment of fecal incontinence. In the early 1990s, research appeared that documented the normal anal sphincter complex and its components 1-3 . Mapping out the normal appearance of the internal and external sphincters allowed actual visualization of defects in the anal sphincter. Prior to this, patients with fecal incontinence (mostly women) were evaluated with physical exam, anal physiology, and needle electromyelogram (EMG) 4-6 . This limited...

Critical Choice of an Effective Diagnostic Workup

Every kind of examination should contribute to the diagnosis, offering an interpretation key of the pathophysiology of a certain disease. Diagnostic assessment, provided by a panel of clinical and instrumental tests, should be finalized to plan the treatment, and those tests should legitimate the therapy chosen. There is evidence concerning the usefulness of anorectal testing in the diagnostic workup of FI it can add diagnostic information in 19-98 of patients, influence the management plan in...

Role of Epidural Anesthesia

Regional anesthesia for the relief of labor pain has become more popular over the past 20 years. Some studies suggest that epidural analgesia, by enabling relaxation of the pelvic floor, leads to greater control of delivery of the fetal head and consequently fewer perineal lacerations 39 , but prolongation of the second stage of labor may also increase the incidence of pudendal nerve damage 40,41 . Robinson et al. 42 recently examined the relationship between epidural analgesia and perineal...

Mechanisms of Faecal Incontinence in Diabetes

As discussed elsewhere in this volume, defecation involves close integration of the peripheral autonomic and enteric nerves. Therefore, it is reasonable to infer that ischaemic or toxic damage to these nerves caused by diabetes can lead to disorders of defecation that will vary according to the site and type of nerve(s) that are affected. As mentioned, it is important to not attribute the disturbances in defecation that occur in patients with diabetes as necessarily complications of diabetes...

Etiology of Fecal Incontinence

Fecal incontinence occurs when one or more mechanisms that maintain continence are disrupted to an extent that another mechanism(s) is unable to compensate. Thus the cause of fecal incontinence if often multifactorial 13-17 . In a prospective study, 80 of patients had more than one pathogenic abnormality 17 . Following is a list of important information that should be elicited when taking a history in a patient with suspected fecal incontinence - Onset and precipitating event(s) - Duration,...

Evaluation

The evaluation begins as a comprehensive history. Questions to define the patients' symptoms and their onset and to exclude other causes of fecal incontinence are essential. An obstetric history includes number and mode of deliveries, birthweight, complications of the pregnancy or labor, whether an episiotomy was performed, perineal wound complications, and postpartum infections. Prior anorectal surgery is noted. Concomitant symptoms of urinary continence and or organ prolapse are also...

Fecal Incontinence in Disease Mainly Affecting the Brain

Loss of control of the ascending and descending pathways induced by lesions in the CNS may present with urinary and fecal incontinence. Any supraspinal lesion of brain, brainstem, and spinal cord rostral to the sacral Onufs nucleus-including cerebrovascular disease, hydrocephalus, intrinsic or extrinsic tumors, traumatic head injury, multiple sclerosis, Parkinson's disease (PD) and other neurodegenerative diseases, and spinal cord injury (SCI)-may affect voiding and fecal continence....

Diagnostic Assessment

In patients submitted to RR for cancer, clinicians must dedicate attention in investigating defecation disorders. In fact, a variety of dysfunctions can occur considering the multifactorial etiology of FI in these patients, particularly when integrated therapies have been associated to surgery. Increased bowel frequency only or associated with fecal soiling or seepage should be of concern. Tenesmus is not infrequent, and incontinence to gas could coexist. In more severe cases, incontinence to...

Central Nervous System Cerebrovascular Accidents

Faecal incontinence may affect up to 40 of subjects immediately following a stroke, with a frequency of up to 15 of those who survive 3 years. It is associated with a higher mortality and greater likelihood of need for long-term (institutional) care (exceeding dementia as a reason for requesting nursing home placement). In the immediate poststroke period, incontinence has been shown to be associated with female gender, a history of previous stroke, and comorbidity of other disabling diseases,...

Clinical Assessment

As with all cases of faecal incontinence, a comprehensive history including documentation of potential sphincter injury and thorough physical examination are essential. Many techniques have been employed to elucidate the pathophysiology of faecal inconti nence, but the majority of them are used primarily as research tools. The objective of clinical assessment is to characterise the type and severity of faecal incontinence, including awareness of the desire to defecate prior to incontinence, and...

Anorectal Manometry and Sensory Testing

Anorectal manometry with rectal sensory testing is the preferred method of defining functional weakness of the external and internal anal sphincters and for detecting abnormal rectal sensation 49 . Anorectal manometry not only provides an objective assessment of anal sphincter pressures but also assesses rectal sensation, rectoanal reflexes, and rectal compliance 49 . Currently, several types of probes and pressure-recording devices are available, and each system has distinct advantages and...

Indications and Contraindications for the ABS

Many factors, both anal and extra-anal, contribute to fecal continence. It is apparent that the achievement of the ABS is restoring a high-pressure zone in the anal canal in a static manner, with no ability to increase pressure in the event of a threat to continence. The ABS corrects the loss of resting anal pressure. It would thus be fallacious to assume that normal continence can be restored by this means, even though the functional results obtained are highly satisfactory. The best...

Future Directions

The future direction of SNS in the context of anorec-tal dysfunction is in part already outlined by current research. Various interrelated clinical and technical issues are addressed by ongoing research efforts aimed at increasing our knowledge of the appropriate use of SNS and its mechanism of action. A broad spectrum of patients is today successfully selected by the current pragmatic approach. Recently, some small case series and individual case reports have investigated the effect of SNS in...

Direct Health Care Costs

Fecal incontinence is a very particular case in that some items of expenditure are not attributable to a single agent. Indeed, the local health care authorities (territorial bodies responsible for financing and providing health care services for the residents in their area) often bear some costs (direct health care costs), which are subsequently borne by the patient (direct non-health care costs). Costs related to diagnostic tests and hospitalization are unequivocally attributable to the NHS....

Operation

Although initial reports suggested that the success of sphincteroplasty was contingent on a prior colostomy, multiple series have shown equivalent results of efficacy and safety without fecal diversion 5,16 . In the setting of multiple failed previous repairs, however, diverting ostomy may still be valuable. There are no trials that specifically define the benefit of bowel preparation and perioperative antibiotics. It is nevertheless generally accepted that patients should undergo full...

Diet and Patient Education

Patients should be educated to avoid excessive straining at defecation to reduce the risk of pudendal nerve damage. Perianal hygiene must be addressed, including delicate soaps specifically for use in the perianal area, to avoid perianal irritation and pruritus. Only in selected cases should absorbents, diapers, and tampons be recommended. Patients must be educated to reduce or avoid foods that induce loose stools, excessive gastrointestinal transit, or increased intestinal gas production...

Indication

Dynamic graciloplasty (DGP) is a major procedure and must be reserved for the most severe forms of fecal incontinence. It is indicated for patients who have a proven sphincter defect and no other reasons for incontinence. There are other therapeutic options for patients with sphincter defects, and it is necessary to investigate all factors contributing to incontinence before a decision is made. The original sphincter can be examined with endoanal sonography to determine the extent of the defect...

Surgical Results Outcomes of Primary Repair

Several factors contribute to the outcome of primary repair. Fernando and colleagues 42 found wide variation in the experience of acute anal sphincter repairs in a survey of obstetricians and gynecologists in the UK. At the time of delivery and injury, edema and blood may prevent adequate exposure to the muscle, complicating identification of the muscle layers and therefore preventing an optimal repair 49 . Different techniques are used to primarily repair the acute sphincter tear. Primary...

Incontinence with Anorectal Sphincteric Abnormalities

The remaining ambulatory elderly patients with fecal incontinence will exhibit one or a combination of abnormalities of continence mechanisms. Most can be ascertained when a directed physical examination is performed by a skilled and experienced examiner 14, 18 . For example, the tone of the internal anal sphincter and the contractile strength of the external anal sphincter can be assessed by digital examination of the anal canal at rest (largely reflecting internal anal sphincter function) and...

Pathophysiological and Behavioral Aspects

Further studies investigating pathophysiological mechanisms of FI is of crucial importance because progress will have an impact on both diagnostic and therapeutic strategies. Due to the possible multifactorial origin of FI and the existence of different clinical presentations, basic research into the influence played by each of the numerous factors involved in continence control can be of help 2 . Future studies must consider that the traditional assumption that women younger than 65 years of...

Anovaginal and Rectovaginal Fistula Repair

Anovaginal and rectovaginal fistulas are uncommon injuries resulting from vaginal delivery however, obstetric injury is the most common cause of these fistulas 114 . Injury to the perineum during vaginal delivery and poor healing of primary repair of per-ineal tears are the main causes of the obstetric-induced rectovaginal fistula 115 . A small percentage will heal spontaneously after resolution of acute edema and inflammation, if the fistula is still present, there is usually well-vascularized...

Rehabilitative Techniques

The rehabilitative techniques that may be used for treating fecal incontinence are Biofeedback therapy is an operant conditioning 5 that consists of pelvic floor strengthening exercises together with visual verbal feedback training 6 . It is voluntary, employs a trial-and-error process by which learning takes place, and the subject must be aware of the desired response (signals). Two types of biofeedback training, manometric or electromyo-graphic (EMG), can be used in fecal incontinence, but...

Accuracy of Demonstrating Anorectal Sphincter Injury with Anal Ultrasound

EUS remains the gold standard in delineating the anatomy of the PR muscle and anal sphincter complex 18, 21,43-45 . EUS can visualize defects, scarring, thinning and thickening, difference in echogenicity, and other local alterations. The defects should be described, indicating their location (IAS, EAS, PR muscle), their size longitudinally (total, proximal, distal), and their circumference (degrees). Some semantic problems exist concerning the words defect, tear, scar, and fibrosis. Clear...

Anal Instrumentation for Anastomosis General Introduction

Anterior resection and proctectomy with ileoanal pouch formation are the two main operations performed in the pelvis that involve anastomosis performed either by inserting a staple gun transanally or by hand-sewn transanal colo- or ileoanal anastomosis. Transanal stapling devices have allowed easier performance of low anastomoses and led to a reduction in the number of abdominoperineal excisions 52 . Use of these stapling devices, however, may be associated with disturbance of continence 53 ....

Gracilis versus Gluteus

No randomized, controlled trials exist to compare the efficacy of the gluteus maximus muscle to the gracilis muscle in creating a neosphincter. Certain factors, such as anatomy and function, as well as the primary reason for fecal incontinence, dictate decision making. At our institution, the gluteus muscle is preferred in patients who require considerable muscle bulk, who need moderate resting tones with high squeeze pressures, who would benefit from a complete rectum wrap, and who have...

Implantation Technique Perioperative Care

Preoperative care includes careful cutaneous and bowel preparation over a 48-h period. Two douches of the operative field are performed daily with an iodinated solution, and complete colonic preparation is done, including X-prep and enemas, until fluid becomes clear. There is no need for a colostomy, except in the case of diarrheic patients in whom contamination of the perineal wound may occur from too rapid a resumption of bowel movements. Antibiotic prophylaxis based on a third-generation...

Surgical Approach and Operative Technique

At our institution, preoperative evaluation includes assessment by a multidisciplinary team that comprises members from general surgery, plastic surgery, urogynecology, and gastroenterology. Workup involves a combination of sigmoidoscopy, endorectal ultrasound, rectal manometry, and pudendal nerve studies. The information provided by these studies helps identify patients with fecal incontinence who are suitable operative candidates, specifically those individuals with good rectal vault...

References

Cook TA, Mortensen NJ (2002) Colon, rectum, anus, anal sphincters and the pelvic floor. In Pemberton JH, Swash M et al (eds) The pelvic floor its function and disorders. Harcourt, London, pp 61-76 2. Lau ST, Caty MG (2006) Hindgut abnormalities. Surg Clin North Am 86 301-316 3. Mahmoud N, Ross, H Fry, R (2004) Colon and rectum. In Towsend CM, Beauchamp RD et al (eds) Sabiston Textbook of Surgery. W.B. Saunders, New York 4. Hjartardottir S, Nilsson J, Petersen C et al (1997) The female pelvic...

Sphincteric Risk Factors Obstetric Events

With respect to acquired faecal incontinence in women, we have recently reported the results of a (necessarily) retrospective cohort analysis of 475 women referred to our Gastrointestinal Physiology Unit for investigation of their symptoms of faecal incontinence 92 . The pertinent findings of that study can be summarised as follows The median age of symptom onset was 47 years and symptom duration 26 (range 2-502) months, with symptomatology usually being combined passive and urge incontinence....

Fecal Incontinence in Myopathies

Anal sphincter function in myopathies has been investigated infrequently. In myotonic dystrophy, most patients suffer from diarrhea and abdominal cramps. Different studies showed widespread abnormalities of gastrointestinal motility in myotonic dystrophy, involving the esophagus and small and large intestines 84-87 . Dysphagia is a prominent symptom in myotonic dystrophy patients, with a reported prevalence of 25-85 in different series. Impaired pharyngeal contraction, myotonia of the tongue...

Functional Anatomy and Physiology

Fecal continence is a complex function that requires coordinated responses in the pelvic floor sphincter muscles and abdominal and anorectal muscles. Consequently, fecal incontinence occurs when the normal anatomy or physiology of the anorectal unit is disrupted. In most cases, different pathophysiological mechanisms are involved in the pathogenesis of fecal incontinence, resulting in multifactorial etiology 3 . Physiological interaction of rectal motility and sensation with the tonic activity...

Mechanisms of Continence and Defecation

The mechanisms that maintain fecal continence include anatomical factors (i.e., the pelvic barrier, the rectal curvatures, and the transverse rectal folds), recto anal sensation, and rectal compliance. Stool is often transferred into the rectum by colonic high-amplitude-propagated contractions, which often occur after awakening or meals 54 . Denny-Brown and Robertson observed that rectal distention evoked rectal contraction and anal sphincter relaxation, facilitating evacuation 28 . The pelvic...

University of North Carolina Clinical Experience

From 1996 to 2004, we performed functional unilateral gluteoplasty in 25 patients with severe fecal incontinence. Using a modified Pescatori grading system to assess continence for solid stool 37 , we determined that gluteoplasty was successful in 18 patients (72 ) and partially successful in four (16 ). Gluteoplasty was defined as successful if patients had less than one episode of incontinence per week, partially successful if one to three episodes per week, and not successful if greater than...

Depression Shame and Isolation

In the study by Collings and Norton 18 , shame and embarrassment were common, and depression, stress, isolation, secrecy, poor self-image and sexual avoidance or aversion were also reported. These narrative-based findings tie in well with results from other studies. Amongst adolescents with FI, psychosocial impairment was significant on the Child Assessment Schedule, the Child Behaviour Checklist and the Youth Self Report 19 . In a study of community-dwelling adults, FI was found to have a...

Diagnosis

The four-grade classification after Browning and Parks has been the standard for clinically grading fecal incontinence for many years 11 . Grade I means involuntary loss of gas, grade II is soiling, grade III means loss of solid material, and grade IV refers to complete incontinence. The Jorge and Wexner questionnaire 12 , which comprises an estimation of leakage frequency with the need to wear a pad and the overall effect on lifestyle, has become widely used since its implementation in 1993....

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

Sphincter Operation

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...

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...

Hypothesis of Pathophysiology

Various causes (including reduction of the rectal ampulla, iatrogenic internal sphincter lesions, auto-nomic nerve lesions, influence of chemoradiation) could play a role in determining this dysfunction. A sphincter-saving RR significantly reduces the rectal ampulla frequently, excision of the entire rectum is necessary, and coloanal anastomosis is performed 5, 23-27 . Even if a colonic pouch is constructed, FI may still occur 5, 23, 28 . However, the role of methods of reconstruction appears...

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

Anal Sphincter Ultrasound

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...

Preoperative Assessment

Operative intervention is undertaken in patients in whom appropriate assessment has been performed. This includes a careful history, clinical examination, endoanal ultrasound and anal manometry. Further tests that may be useful are a defecating proctogram, pudendal nerve terminal motor latency PNTML and needle electromyelogram EMG . If these investigations identify a defect in the external sphincter, then the patient should undergo a sphincter repair rather than a postanal repair. Rectal...

Anal Sphincter Tone and Reflexes Internal Anal Sphincter

Sphincter Pussy

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 ....

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...