Impaired anal sensation and early diabetic faecal incontinence.

Faecal incontinence develops in up to 20% of diabetic patients. To try to determine the relative contributions of sensory and motor neuropathy in this troublesome complication, anorectal function was examined in 10 male diabetic patients with early faecal incontinence (mucus leakage or faecal staining without the need to wear a pad), 10 asymptomatic male diabetic patients, and 10 normal control subjects. Motor function was tested using anal manometry to determine the resting and maximum squeeze pressure, and the functional anal canal length. No significant differences were found between the groups. Sensory function was tested by measuring the mucosal sensitivity to electrical stimulation, and the response to inflation of a balloon in the rectum. In the mid-anal canal position the symptomatic patients had a significantly higher sensory threshold at 6.6 +/- 2.8 mA compared with 3.0 +/- 1.2 mA in the normal control subjects (p less than 0.002), and in the high anal zone symptomatic patients had a significantly elevated sensory threshold at 9.1 +/- 2.0 mA compared with 4.6 +/- 1.6 mA in asymptomatic patients and 3.6 +/- 1.3 mA in the normal control subjects (both p less than 0.001). There were no significant differences in the first sensation of fullness, maximum tolerated volume or percentage fall from resting pressure between the groups on inflation of the balloon. Elevation of the sensory threshold in the upper anal canal is an early abnormality in the development of diabetic faecal incontinence.     

Customized biofeedback therapy improves results in fecal incontinence

Background and aims Biofeedback therapy has been extensively used and accepted in fecal incontinence, but reports of its efficiency vary. We evaluated feedback therapy efficiency when (a) selecting the patients subject of the therapy, and (b) customizing the therapy protocol used for each patient.Patients and methods Fifty-three patients with fecal incontinence were selected for biofeedback training. The treatment program was customized for each patient depending on the underlying dysfunction, the patients cooperative and learning attitude, and the patients progress. Biofeedback efficiency was measured using clinical scores, subjective satisfaction of the patient, and manometry.Results Incontinent scores showed improvement in 66% of patients and good improvement in 11% and 15%, respectively, indicating an overall excellent effect of the therapy. Subjective satisfaction was strongly correlated with the previous incontinent scores. Comparison of manometry parameters before and after biofeedback therapy, including maximum anal resting, maximum anal squeeze pressure, and maximum duration of the squeeze, all showed significant differences. In addition, the sensory threshold significantly decreased after biofeedback therapy. Clinical improvements were maintained during the following 12 months.Conclusion Biofeedback improves objective and subjective parameters of anorectal function. Selection of patients and customization of the therapy program increased biofeedback efficiency for the treatment of fecal incontinence.     

Long-term results of electromyographic biofeedback training for fecal incontinence

PURPOSE: The aim of this study was to examine the long-term results of electromyographic biofeedback training in fecal incontinence. METHODS: Thirty-seven patients (1 male) received a customised program of 2 to 11 (median, 3) biofeedback training sessions with an anal plug electromyometer. Nine patients had persistent incontinence after anal sphincter repair, a further 8 patients had postsurgical or partial obstetric damage of the sphincter but no sphincter repair, 9 patients had neurogenic sphincter damage, and 11 patients were classified as having idiopathic fecal incontinence. Duration of voluntary sphincter contraction was measured by anal electromyography (endurance score) before and after treatment. A postal questionnaire was used to investigate the following variables: 1) subjective rating on a four-grade Likert-scale of the overall result of the biofeedback training; 2) incontinence score (maximum score is 18, and 0 indicates no incontinence); and 3) rating of bowel dissatisfaction using a visual analog scale (0 to 10). RESULTS: Twenty-two patients (60 percent) rated the result as very good (n=8) or good (n=14) immediately after the treatment period. Median endurance score improved from 1 to 2 minutes (P<0.0001). Median incontinence score improved from 11 to 7, and bowel dissatisfaction rating improved from 5 to 2.8 (bothP<0.0001). After a median follow-up of 44 (range, 12–59) months, 15 patients (41 percent) still rated the overall result as very good (n=3) or good (n=12). The incontinence score did not change during follow-up. Median bowel dissatisfaction rating deteriorated from 2.8 to 4.2 but remained better than before treatment. Poor early subjective rating and the need for more than three biofeedback sessions were predictive of worsening during follow-up. CONCLUSION: We think it is encouraging that in this study biofeedback treatment for fecal incontinence with an intra-anal plug electrode resulted in a long-term success rate in nearly one-half of the patients.     

Multimodal rehabilitation for faecal incontinence: experience of an Italian centre devoted to faecal disorder rehabilitation

Abstract. Background: Sphincter exercises and biofeedback therapy have been used to treat faecal incontinence but results have been unpredictable and standards of treatment have not yet been established. The aim of this study was to retrospectively evaluate the effects of a new multimodal rehabilitation model on faecal incontinence. Methods: All of the rehabilitative procedures are guided by manometric data. Primary study outcome criteria were the determination of changes or deterioration in incontinence, failure to achieve full continence and/or presence of faecal urgency. The clinical outcome was designed according to the Jorge-Wexner incontinence score. Results: Between 1997 and 2001, one hundred forty-nine incontinent patients (85 F and 64 M; age range, 41–73 years; mean age, 60.6 years) underwent multimodal rehabilitation at our outpatient unit. The overall mean incontinence score had significantly improved after treatment (p<0.001), and 58 patients (38.9%) were symptom free. No patient reported any deterioration in incontinence. Faecal urgency persisted in 23 patients (15.4%). Conclusion: In conclusion, multimodal rehabilitation, using manometric study, can modify the incontinence score.     

The effects of low-frequency endo-anal electrical stimulation on faecal incontinence: a prospective study

Background and aims Faecal incontinence is a distressing problem that is often not amenable to surgical correction. Chronic low-frequency electrical stimulation of damaged axons is thought to reduce synaptic resistance, increase the size of motor units by axonal sprouting and increase the rate of conduction of the pudendal nerve. The aim of this study was to prospectively evaluate the effect of chronic low-frequency endo-anal electrical stimulation on faecal incontinence using a home-based unit and hospital-supervised therapy.Materials and methods Forty-eight patients with faecal incontinence completed a prospective randomised trial. Patients were allocated randomly to one of two groups; group 1 was exposed to endo-anal pudendal nerve stimulation daily at home with a portable home unit, group 2 attended the physiotherapy department for endo-anal electrical stimulation under supervision.Results Continence scores improved significantly after treatment in both groups (p<0.001). Both groups showed improved manometric scores, although only group 1 showed significant improvement in both resting and squeeze pressures (mean total resting pressure 184–224 mmHg, p<0.001; mean total squeeze pressure 253–337 mmHg, p<0.001). This was also reflected by an improvement in quality of life in both groups.Conclusions Low-frequency endo-anal electrical stimulation significantly improves continence scores and quality of life in patients with faecal incontinence not amenable to surgical correction. It leads to improved manometric values when carried out on a daily basis with a portable home unit.     

Investigating and treating fecal incontinence: When and how

Fecal incontinence is a common disorder in our aging population and can have profound effects on patient’s well-being. The present review examines the current understanding of fecal incontinence and provides a practical approach to the investigation and management of this condition. A special emphasis is placed on specialized testing, focusing on indications and impact on guiding management.     

Perineal retraining improves conservative treatment for faecal incontinence: A multicentre randomized study

BackgroundAnal incontinence is a frequent complaint that profoundly affects quality of life. Our aim was to determine whether perineal retraining gives additional benefits to standard medical treatment.MethodsPatients with anal incontinence and a Wexner score >4 were randomly assigned to standard conservative treatment (control) or perineal retraining, including biofeedback, in addition to standard treatments (biofeedback). Diaries, self-administered questionnaires and satisfaction scores quantified the benefits. Self-evaluated improvement was the primary outcome measure. A score ≥3 (in an improvement scale from −5 to +5) defined success.ResultsOverall, 157 patients were included; 80 in the control group (75% females, mean age 60.1 ± 13.2 years) and 77 in the biofeedback group (79% females, mean age 61.9 ± 10.2 years). After a 4-month follow-up, the success rate was significantly higher in the biofeedback group (57% versus 37%; p < 0.021). In the biofeedback group, daily stool frequency, leakage, and faecal urgency significantly decreased, and daily non-urgent perception of stool increased. Conversely, symptomatic scores and quality of life scales did not significantly differ between groups. In a multivariate model, the adjusted odds ratio showed that perineal retraining was significantly associated with a higher chance of self-rated improvement (adjusted Odd Ratio [95%CI]: 2.34 [1.14–4.80]; p = 0.021).ConclusionsPerineal retraining offers a moderate but significant benefit for patients suffering from anal incontinence.     

Fecal incontinence after minor anorectal surgery

PURPOSE: Fecal leakage after open lateral internal anal sphincterotomy for chronic anal fissure is common, but underreported. The aim of this study was to prospectively assess the physiologic and morphologic effects of sphincterotomy, comparing continent and incontinent patients after surgery. This group was further compared with an unselected group of patients presenting with incontinence after hemorrhoidectomy. METHODS: Between January 1997 and June 1999, 23 patients were prospectively followed up through internal sphincterotomy with conventional and vector volume anorectal manometry, parametric assessment of the rectoanal inhibitory reflex, and endoanal magnetic resonance imaging. Fourteen continent patients were compared with 9 incontinent postoperative cases, 9 patients referred with incontinence after hemorrhoidectomy, and 33 healthy volunteers without anorectal disease. RESULTS: Significant differences were noted between continent and incontinent postsphincterotomy cases for all resting conventional and vector volume parameters and for some squeeze parameters. Although there was a significant reduction in postoperative high pressure zone length at rest, there were no differences between the postoperative groups. There was an increase in sphincter asymmetry of 6.7 percent (± 3.5 percent) in incontinent postsphincterotomy patients and a decrease of 2.8 percent (± 3.2 percent) in continent cases. Significant differences were noted for resting parameters between incontinent postsphincterotomy and posthemorrhoidectomy patients, with a higher resting sphincter asymmetry in the latter group. The area under the rectoanal inhibitory curve was smaller in postsphincterotomy incontinent patients when compared with continent cohorts over the distal and intermediate sphincter zones at rest with a reduced latency of inhibition. There was no difference in the magnetic resonance images of the sphincterotomy site between incontinent and continent postsphincterotomy cases and no posthemorrhoidectomy case had evidence of sphincteric damage. CONCLUSION: There are complex significant differences in the postoperative physiology of patients undergoing lateral internal sphincterotomy who become incontinent when compared with those who maintain continence. These physiologic changes are not reflected in detectable morphologic sphincteric differences. It is unknown whether these changes predict for long-term incontinence, and it is suggested that postoperative incontinence after minor anorectal surgery is not necessarily related either to a preexisting sphincter defect or inadvertent intraoperative sphincter injury.This work was performed at the Hammersmith Hospital London Imperial College School of Science Technology and Medicine. Presented at the Section of Coloproctology at the Royal Society of Medicine, London, United Kingdom, March 22, 2000, at the Annual Meeting of the Israeli Society of Colon and Rectal Surgery, Nazareth, Israel, September 24 to 27, 2000, and as a poster at the Congress of the European Council of Coloproctology, Prague, Czech Republic, April 29 to May 2, 2001 (winner of the poster prize).     

Prospective evaluation of a new device for the treatment of anal fistulas

AIM: To evaluate the safety of the implantation of a new device for the treatment of anal fistulas. The short-term clinical efficacy was also assessed. METHODS: This study took place at a tertiary care university hospital. Patients with a complex anal fistula of cryptoglandular origin were enrolled in the study and were treated with insertion of the new device. All patients were evaluated by clinical and physical examination, including an endoanal ultrasound at the baseline, and then at the 2 wk and 1, 2, 3 and 6-mo follow-up visits. RESULTS: Morbidity, continence status, and success rate were the main outcome measures. Ten patients underwent the placement of the new device. The fistulas were transphincteric in eight patients and extrasphincteric in the remaining two. The median duration of the surgical procedure was 34.5(range, 27-42) min. Neither intra- nor postoperative complications occurred, and all patients were discharged the day after the procedure. At the 6-mo follow-up evaluation, the final success rate was 70%. Three failures were registered: a device expulsion(on the 10 th postoperative day), the persistence of inflammatory tissue around the fistula tract(at the 2-mo follow up), and the persistence of serum discharge(at the 6-mo follow up). No patient experienced any change incontinence, as assessed by the Cleveland Clinic Fecal Incontinence score. CONCLUSION: The technical procedure is simple and has low risk of perioperative morbidity. The pre- and post-operative continence status did not change in any of the patients. The initial results at the 6-mo follow up seem to be promising. However, a longer follow-up period and a larger sample size are needed to confirm these preliminary results.     

Relaxation biofeedback conditioning as treatment of a disturbed defecation reflex

The case history is presented of a patient with a disturbed defecation reflex by viral encephalopolyradiculoneuritis. The inability to defecate was thought to be due to hyper-reflexibility and, hence to increased spasm of the external anal sphincter. Normal defecation was eventually brought about by an operant learning technique, as described originally by Haskell and Rovner. The patient was conditioned to relax his external anal sphincter once he felt rectal fullness and the urge to defecate. Defecation was initiated by a Dulcolax^® suppository.     

生物反馈治疗大便失禁的疗效评价

目的　评价生物反馈方法治疗大便失禁患者的疗效。方法　对 2 6例大便失禁患者进行生物反馈治疗 ,治疗前后分别做肛肠测压和肌电图检查 ,评价患者的肛门功能。结果　 2 6例患者肛管最大收缩压、收缩肌电振幅、持续收缩时间、直肠感觉阈值和感觉收缩时间治疗前、后均有显著差异 (P <0 .0 1)。结论　生物反馈治疗大便失禁有效     

Faecal incontinence after internal sphincterotomy for anal fissure

Minor defects in continence following open lateral sphincterotomy are relatively common. This study prospectively assessed 28 patients undergoing lateral sphincterotomy for chronic anal fissure. There were substantial differences in both resting and squeeze anal pressures and vector volumes in the incontinent cohort when compared to the continent post-operative cases. Mean preoperative high pressure zone was 37.6 mm, significantly higher than the postoperative value of 17.0 mm (p < 0.001). There was a significant difference in percent asymmetry of the anal canal at rest between incontinent and continent post-sphincterotomy cases, with a 6.7% increase in the former group and a 3.1% fall in the latter group (p < 0.001). It is unknown whether these changes are predictive for long-term continence. Received: 28 January 2000 / Accepted in revised form: 14 March 2000     

Combined biofeedback, physiotherapy and electrostimulation for fecal incontinence

Different outcomes are reported in the literature following pelvic floor rehabilitation for fecal incontinence, possibly due to the type of procedure employed, whether biofeedback or physiotherapy or electrostimulation. The aim of the present study is to analyze the results achieved in a group of patients treated with a combination of the three procedures. Thirty-two patients (24 females) affected by fecal incontinence underwent a course of combined rehabilitation (CR); 23 of them had anal surgery prior to CR, for rectal mucosal prolapse and hemorrhoids in most cases. Eighteen had anal manometry before and after CR. Sixteen underwent anal ultrasound prior to treatment. Patients were taught perineal exercises, biofeedback was either sensory or electromyographic, and electrostimulation was performed with a 10–20 MHz endoanal probe. Twenty-seven patients were available for follow-up. The mean incontinence score improved from 4.0±0.8 to 2.1±1.7 (mean±sd) (p<0.001); 19 patients (70%) were satisfied after CR, and 11 (44%) were fully continent. Post-treatment manometry showed an increased amplitude of squeeze pressure in 50% of the cases, whereas 61% had an increase in duration, but only 27% of them had a positive clinical outcome. Rectal evacuation thresholds improved in 55% of the cases and 86% of them had a corresponding positive clinical outcome. At ultrasound, 6 patients showed intact anal sphincters and had a positive outcome following CR. Pelvic floor rehabilitation seems to be effective for the management of fecal incontinence when carried out combining different types of procedures. No significant correlation was found between manometric and clinical response to the treatment. An increase of rectal sensation may be responsible for the clinical improvement. Received: 25 August 2000 / Accepted in revised form: 20 October 2000     

Use of endoanal ultrasound in patients with rectovaginal fistulas

PURPOSE: The purpose of our study was to define the role of endoanal ultrasound in the evaluation and management of patients with rectovaginal fistula. METHODS: A retrospective review was performed of all patients with rectovaginal fistula who were evaluated by endoanal ultrasound at Barnes-Jewish Hospital at Washington University from 1992 to 1997. RESULTS: Twenty-five females underwent endoanal ultrasound before rectovaginal fistula repair. Mean age was 34 years. Rectovaginal fistulas were caused by obstetric trauma (19 patients; 76 percent), cryptoglandular disease (5 patients; 20 percent), and Crohn's disease (1 patient; 4 percent). Previous rectovaginal fistula repair had been performed in ten patients (40 percent). A history of anal incontinence was present in ten patients (40 percent). Rectovaginal fistula location was above (15 patients), at (7 patients), or below (3 patients) the dentate line. Rectovaginal fistula size was <5 mm (19 patients; 76 percent) or >5 mm (6 patients; 24 percent). Anal manometry revealed decreased sphincter pressures (resting or squeeze) in 12 patients (48 percent). Pudendal nerve latency was abnormal in three patients (9 percent). Endoanal ultrasound identified the rectovaginal fistula in 7 patients (28 percent) and an anterior sphincter defect in 23 patients (92 percent). At surgery sphincter injuries were identified in 23 patients (92 percent). Treatment was either sliding flap repair with anal sphincter reconstruction (22 patients; 88 percent) or sliding flap repair alone (3 patients; 12 percent). Repair of the rectovaginal fistula was successful in 23 patients (92 percent). Complications occurred in 11 patients (44 percent): two recurrent rectovaginal fistulas, five infections, two skin separations, one ectropion, and one hematoma. The two patients with recurrent rectovaginal fistula had prior repairs, and both were subsequently repaired successfully. Of the 11 patients with preoperative anal incontinence, 6 patients (54 percent) were continent and 2 (18 percent) improved after surgery. Cause, size, location, and previous repair of fistula had no effect on final outcome. CONCLUSIONS: Noncontrast endoanal ultrasound was not useful in imaging rectovaginal fistulas and cannot be recommended as a diagnostic or screening tool for the identification of a rectovaginal fistula. However, we recommend that endoanal ultrasound be performed preoperatively in all patients with known rectovaginal fistulas to identify and map occult sphincter defects. Concomitant anal sphincter reconstruction should be considered strongly in patients with rectovaginal fistula and an endoanal ultrasound-documented sphincter defect.Read at the meeting of The American Society of Colon and Rectal Surgeons, San Antonio, Texas, May 2 to 7, 1998.     

The artificial bowel sphincter for faecal incontinence: a single centre study

Background and aims Faecal incontinence (FI) is a socially devastating problem. The treatment algorithm depends on the aetiology of the problem. Large anal sphincter defects can be treated by sphincter replacement procedures: the dynamic graciloplasty and the artificial bowel sphincter (ABS). Materials and methods Patients were included between 1997 and 2006. A full preoperative workup was mandatory for all patients. During the follow-up, the Williams incontinence score was used to classify the symptoms, and anal manometry was performed. Results Thirty-four patients (25 women) were included, of which, 33 patients received an ABS. The mean follow-up was 17.4 (0.8–106.3) months. The Williams score improved significantly after placement of the ABS (p < 0.0001). The postoperative anal resting pressure with an empty cuff was not altered (p = 0.89). The postoperative ABS pressure was significantly higher then the baseline squeeze pressure (p = 0.003). Seven patients had an infection necessitating explantation. One patient was successfully reimplanted. Conclusion The artificial bowel sphincter is an effective treatment for FI in patients with a large anal sphincter defect. Infectious complications are the largest threat necessitating explantation of the device.     

Reasons for non-disclosure of faecal incontinence: a comparison between two survey methods

Purpose We explored reasons for discordance in disclosure of faecal incontinence (FI) between 2 measurement instruments: the Self Administered Faecal Incontinence Questionnaire (SAFIQ) and the Cleveland Clinic Florida Fecal Incontinence Score (CCF-FI) Methods Patients ≥18 years attending the urogynaecology (n=135) and colorectal (n=148) outpatient clinics at The Townsville Hospital, a referral centre serving regional North Queensland, Australia, were invited to complete the SAFIQ and answer questions from the CCF-FI asked by their treating doctor. Selected patients undertook semistructured interviews. Results 262 patients completed both questionnaires. The prevalence of FI in this population was 25.6% (SAFIQ) and 29.9% (CCF-FI). 24% disclosed FI on both instruments, 3.1% on SAFIQ only and 6.1% on CCF-FI only. Major reasons for non-disclosure were: FI historical but not current; problem not considered as FI by patient; SAFIQ too long; condition embarrassing; doctor considered too busy; patient wanted to focus on primary reason for consultation; and doctor explained that a one-off bout of uncontrollable diarrhoea was not FI. Interviewees reported they would respond to FI questions initiated by their general practitioner (GP) during regular consultations, or in a generic questionnaire in the GP’s surgery. Conclusions GPs could identify patients with FI by initiating discussions during routine consultations. Such patients could then be referred to colorectal surgeons for treatment. A more specific definition of FI, which excludes historical data and isolated instances of diarrhoea, is desirable. A measurement instrument suitable for population surveys should contain simple language and acknowledge issues of embarrassment.     

Retrograde colonic irrigation for faecal incontinence after low anterior resection

Background and aims  This study aims to evaluate the therapeutic effect of retrograde colonic irrigation in patients with faecal incontinence after a low anterior resection for a rectal carcinoma. Materials and Methods  Patients with a previous low anterior resection, who were selected for treatment with retrograde colonic irrigation for faecal incontinence between 2005 and 2008, were included in the study. The data from the patients were gathered by chart research and an interview by phone. Results  Thirty patients were included in the study. Three patients died and one patient was not able to answer questions due to a cognitive disorder. The data of the remaining 26 patients were analysed. Five patients had already stopped with the retrograde colonic irrigation treatment due to side effects. Twelve of the 21 patients (57.46%) who still performed RCI became completely (pseudo)continent, three patients (14.2%) were incontinent for flatus and six patients (29.4%) were still incontinent for liquid stool. Five patients stopped with the retrograde colonic irrigation treatment due to side-effects. Conclusion  Retrograde colonic irrigation is an effective method to treat patients with faecal incontinence after a low anterior resection for rectal carcinoma. Retrograde colonic irrigation is not invasive and has only mild side effects.     

Pudendal neuropathy and severity of incontinence but not presence of an anal sphincter defect may determine the response to biofeedback therapy in fecal incontinence

PURPOSE: It has been suggested that the severity of fecal incontinence, the presence of pudendal neuropathy, or an external anal sphincter defect does not preclude clinical improvement with biofeedback therapy. A discrepancy, however, is frequently found between subjective improvement and objective results after biofeedback therapy. Our aim was to assess whether severity of fecal incontinence, presence of pudendal neuropathy, or an external anal sphincter defect could influence the results of manometric parameters after biofeedback therapy in patients with fecal incontinence. METHODS: Biofeedback therapy was used to treat 27 patients with fecal incontinence (25 women; mean age, 53; range, 29–74 years), according to a strict protocol. Manometry, pudendal nerve terminal motor latency, and anal ultrasound were performed in all patients before biofeedback therapy. Manometric evaluation of external anal sphincter function was performed after the biofeedback sessions. RESULTS: Eight of 27 patients had a good clinical response to biofeedback, but with no significant difference in their mean amplitude and duration of squeeze pressure before and after biofeedback. There was no relationship between the clinical results of biofeedback therapy and the initial severity of fecal incontinence, pudendal neuropathy, or external sphincter defect. Patients with severe incontinence (incontinence to solids) and pudendal neuropathy failed to improve the amplitude and duration of their maximum voluntary contraction after biofeedback therapy. Patients with mild fecal incontinence (incontinence to flatus, liquids, or both) (P<0.04), without pudendal neuropathy (P<0.02), or with (P<0.05) and without (P<0.05) external sphincter defect improved their external anal sphincter function after biofeedback therapy. CONCLUSION: In patients with fecal incontinence, the severity of symptoms and pudendal neuropathy should be considered as two factors of poor prognosis of favorable manometric results after biofeedback therapy. Improvement, on the other hand, may be expected after biofeedback therapy despite an external anal sphincter defect.Presented at the XXIst congress of the Societé Internationale Francophone d'Urodynamique, Lisbon, Portugal, May 14 to 16, 1998.     

Urinary retention during sacral nerve stimulation for faecal incontinence: report of a case

Sacral nerve stimulation (SNS) was proposed for the treatment of patients with urologic symptoms in 1967 but was not used until 1981. SNS has also proven to be a promising treatment in idiopathic faecal incontinence when conventional treatments have failed. The modality has been used for faecal incontinence since the mid-1990s. Eighty percent of the patients who were selected for percutaneous nerve evaluation (PNE) because of faecal incontinence report an improvement in the symptoms and qualify for a permanent implantation. Accordingly, SNS is now used for faecal incontinence and urologic symptoms. Reflex interactions between the bladder and the distal gastrointestinal tract are well known. The present case shows that SNS for faecal incontinence may significantly influence bladder function.This paper has not been (will not be) presented at any meetings.     

Referral for anorectal function evaluation is indicated in 65% and beneficial in 92% of patients

AIM： To determine the indicated referrals to a tertiary centre for patients with anorectal symptoms, the effect of the advised treatment and the discomfort of the tests.
METHODS： In a retrospective study, patients referred for anorectal function evaluation （AFE） between May 2004 and October 2006 were sent a questionnaire, as were the doctors who referred them. AFE consisted of anal manometry, rectal compliance measurement and anal endosonography. An indicated referral was defined as needing AFE to establish a diagnosis with clinical consequence （fecal incontinence without diarrhea, 3^rd degree anal sphincter rupture, congenital anorectal disorder, inflammatory bowel disease with anorectal complaints and preoperative in patients for re-anastomosis or enterostoma, anal fissure, fistula or constipation）. Anal ultrasound is always indicated in patients with fistula, anal manometry and rectal compliance when impaired continence reserve is suspected. The therapeutic effect was noted as improvement, no improvement but reassurance, and deterioration. RESULTS： From the 216 patients referred, 167 （78%） returned the questionnaire. The referrals were indicated in 65%. Of these, 80% followed the proposed advice. Improvement was achieved in 35% and a reassurance in 57% of the patients, no difference existed between patient groups. On a VAS scale （1 to 10） symptoms improved from 4.0 to 7.2. Most patients reported no or little discomfort with AFE.
CONCLUSION： Referral for AFE was indicated in 65%. Beneficial effect was seen in 92%： 35% improved and 57% was reassured. Advice was followed in 80%. Better instruction about indication for AFE referral is warranted.