Which Tests in Which Condition

Because there are now numerous therapeutic options, it seems justified to intensively evaluate patients with FI to corroborate the choice. Depending upon diagnostic tests only could cause inaccurate pathophysiological assessment and ineffective treatment. The decision process as to which diagnostic tests should be used in a specific clinical condition is inevitably related to the specific attitude developed in a team involved in a patient's evaluation and cure.

In Table 2, a proposed schema of an integrated diagnostic workup is presented. From a general point of view, ARM and rectal sensation assessment should be considered mandatory in almost every clinical condition, being widely performed in coloproctolog-ical laboratories, moderately time consuming, and allowing considerable useful information. However, even if ARM could show a pressure pattern of sphincter asymmetry, it is not enough to diagnose a sphincter lesion; therefore, integration with other diagnostic tests is mandatory. Rectal sensation assessment should be useful to eventually identify alterations due to central or peripheral neuropathy, metabolic diseases (i.e., diabetes), or radiotherapy given for pelvic neoplasms (situated at the anus, rectum, prostate, bladder, or gynecological organs).

Concerning physiological assessment, AREP should play a crucial role, although its use is rather limited because specific experience in electrophysiology is required. EMG performed to map sphincter lesions is no longer frequently used, but it could be of interest to visualize denervation or reinnervation patterns in many clinical conditions (i.e., sphincter atrophy, neuropathies, elderly patients). AREP allows assessment of both anal and rectal threshold sensations, which should be mandatory when investigating FI due to rectal prolapse, after rectal resection or irradiation, in neuropathy and metabolic diseases, and in elderly patients. PNTML assessment could reveal a pudendal neuropathy and, then, be useful in a number of FI cases: in both obstetric and iatrogenic sphincter lesions, being suggested of importance in choosing some therapeutic approach (i.e., sphincteroplasty); in sphincter atrophy; in rectal prolapse or resection; in irradiated patients; in central/peripheral neuropathies; in metabolic diseases; and in FI found in either elderly or pediatric patients. Evoked potentials should complete the AREP evaluation in suspected neuropathies.

In structural assessment of sphincters, there is discussion concerning the preference toward EAUS instead of MR, or vice versa, depending on specific experience in using one test versus the other. In this debate, it should be considered that EAUS can be performed by nonradiologists, and it is usually simpler, more available, and less time consuming and expensive compared with MRI. On the other hand, MRI needs dedicated personnel with specific experience. Therefore, even if both EAUS and MRI should allow similar diagnostic accuracy, in most cases, EAUS is the preferred mandatory test for imaging, with MRI being an optional investigation in the more complex cases. On the contrary, MRI could be used as a first-line imaging, if chosen. Only for specific conditions should clinicians prefer one or the other (i.e., EAUS in suspected IAS atrophy and MRI in suspected EAS atrophy).

Availability of a certain instrumental or diagnostic procedure is a determinant factor in the diagnostic process. In some condition, barium defecography could be the only procedure available to study the functional imaging in the pelvis, whereas in other centers, the availability of dynamic MR could allow a more accurate evaluation. This is the case in FI due to rectal prolapse or when other pelvic disruptions (i.e., rectocele) could have occurred following obstetric sphincter lesions.

Finally, but not negligibly, other procedures could be needed to assess specific problems: proctoscopy in FI due to rectal prolapse (eventual proctitis or solitary ulcer), rectal resection (evaluation of rectal remnant, anastomosis, proctitis), or pelvic irradiation (assessment of proctitis); central nervous system MRI in FI cases of suspected central or peripheral neuropathy; in-depth biochemical assessment in metabolic diseases; psychiatric and psychometric tests in FI elderly; and integration of urologic evaluation in any case of double fecal and urologic incontinence, particularly in pediatric patients.

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