Utility of a combined test of anorectal manometry, electromyography, and sensation in determining the mechanism of ''idiopathic'' faecal incontinence.

Combined tests of anorectal manometry, sphincter electromyography and rectal sensation were carried out in 302 patients with faecal incontinence (235 women, 67 men). The results obtained were compared with 65 normal subjects (35 women, 30 men). A mechanism for incontinence was identified in all and the majority of patients had more than one abnormality. Two hundred and seventy eight patients (92%) had a weak external anal sphincter, 185 of these (67%, mostly women) also showed abnormal perineal descent, and 14 women showed clinical evidence of sphincter damage as a result of obstetric trauma. Ten per cent of patients with impaired external anal sphincter contraction showed associated evidence of spinal disease (impaired rectal sensation plus attenuated or enhanced reflex external anal sphincter activity). Unlike the other groups, the 'spinal' group contained equal numbers of men and women. Ninety seven patients (32%) had evidence of a weak internal anal sphincter. The external sphincter was also very weak and 92% of these patients also had perineal descent. Eighty two patients (27%) showed an unstable internal sphincter, characterised by prolonged 'spontaneous' anal relaxation under resting conditions and an abnormal reduction in anal pressure after conscious contraction of the sphincter or an increase in intraabdominal pressure. One hundred and forty two patients (47%) had a hypersensitive rectum associated with enhanced anorectal responses to rectal distension. All these patients had an abnormally weak external sphincter, suggesting that the hypersensitive or 'irritable' rectum should not be regarded as a cause of faecal incontinence unless accompanied by external sphincter weakness. Twenty four patients (8%) showed a normal basal and squeeze pressures and impaired rectal sensation; six showed giant rectal contractions during rectal distension. The results show that idiopathic faecal incontinence is not caused by a single abnormality, and it is suggested that combined anorectal manometry, electromyography, and sensory testing is a useful technique to identify the causes of faecal incontinence and provide a basis for appropriate treatment.     

Role of manometry, defecography and anal endosonography in the evaluation of colorectal disorders.

OBJECTIVE: altered motility or anatomy of the rectum, anus and perineal floor may lead to symptoms which are unresponsive to routine therapeutic approaches. These disturbances usually lead to constipation, fecal incontinence, or both. Different tests and techniques for evaluating anorectal and perineal disorders, developed in the last two decades, make a better understanding of these disorders possible. This study was designed to evaluate the diagnostic benefits of combining manometry, defecography and anal endosonography in the assessment of patients with anorectal disorders. METHODS: twenty-five children with constipation (with or without soiling), incontinence and/or prolapse underwent anal manometry, defecography and anal endosonography. Group A consisted of 9 children with fecal incontinence, group B consisted of 10 children with constipation with soiling, and group C comprised 6 children with constipation without soiling. RESULTS: in group A resting incontinence was associated with a hypotonic external sphincter in 4 out of 9 patients, 2 of whom had internal anal sphincter thinning. In group B resting incontinence was associated with a hypotonic external sphincter in 8 out of 10 patients, 6 of whom had internal anal sphincter thinning. In group C these associations were not seen in any of the patients. CONCLUSIONS: barium enema is not sufficient for an accurate diagnosis of anorectal disorders. No single test is capable of revealing the type of disease. Anal manometry, defecography and endosonography are complementary procedures in the assessment of this group of disorders. This new approach will improve our knowledge of the pathogenesis of these disorders in children. However, further studies are needed to obtain conclusive evidence.     

Anorectal dysfunction and rectal prolapse in progressive systemic sclerosis

Our aim was to characterize the clinical spectrum of anorectal dysfunction among eight patients with progressive systemic sclerosis (PSS) who presented with altered bowel movements with or without fecal incontinence. The anorectum was assessed by physical examination, proctosigmoidoscopy, and anorectal manometry. There was concomitant involvement of the other regions of the digestive tract in all patients as determined by barium studies, endoscopy, or manometry: eight esophageal, three gastric, four small bowel, and two colonic. Seven patients had fecal incontinence, and four also had second-degree complete rectal prolapse. Abnormal anorectal function, particularly abnormal anal sphincter resting pressures, were detected in all patients; anal sphincter pressures were lower in those with rectal prolapse. Rectal capacity and wall compliance were impaired in seven of seven patients. Successful surgical correction of prolapse in three patients resulted in restoration of incontinence for six months and seven years in two of the three patients. We conclude that rectal dysfunction and weakness of the anal sphincters are important factors contributing, respectively, to altered bowel movements and fecal incontinence in patients with gastrointestinal involvement by PSS. Rectal prolapse worsens anal sphincter dysfunction and should be sought routinely as it is a treatable factor aggravating fecal incontinence in patients with PSS.This work was presented in part at the Annual Meeting of the American Gastroenterological Association, May 1992, and appears in abstract form in Gastroenterology 1992;102:A473.Supported in part by the General Clinical Research Center Grant 00585 from the National Institutes of Health.     

Clinical, manometric, and EMG characteristics of patients with fecal incontinence

Fecal incontinence occurs frequently in both men and women. Yet, few studies on fecal incontinence have separated the evaluation and interpretation of data by gender. This study was designed to identify differences in the clinical, anorectal manometry, and electromyography (EMG) characteristics between male and female patients with fecal incontinence. We compared 53 incontinent males (mean age, 64 years) with 72 incontinent females (mean age, 61 years). Each patient underwent computerized anorectal manometry, and invasive (pudendal nerve conduction studies and concentric needle EMG) and noninvasive EMG (anal sensor surface electrode). An anal incontinence score (AIS) ranging from 0 to 6 was used to categorize patients. Male patients had higher incontinence scores at presentation (AIS greater than 4, 70% vs. 54%). Female patiens had significantly lower resting pressure (40 vs. 53 mmHg, p < 0.05) and more women had sphincter asymmetry (36% vs. 25%, p < 0.05). Both groups had similar PNTMLs (2.41 vs. 2.47 ms). Difference was seen in the net strength of the sphincter (women 4.0 μV vs. men 8.0 μV, p < 0.05), as measured by noninvasive EMG. In conclusion, it is well known that there are differences in anorectal physiologic function between male and female patients with normal continence. Comparing male and female patients with fecal incontinence suggests that female patients tend to have worse sphincter function that men. Both groups had similar EMG alterations, suggesting a common neurogenic injury as etiology. Future studies are needed to address the sexes separately. Received: 18 July 2000 / Accepted in revised form: 6 October 2001     

Anorectal pressure gradient and rectal compliance in fecal incontinence

To study whether anorectal pressure gradients discriminated better than standard anal manometry between patients with fecal incontinence and subjects with normal anal function, anorectal pressure gradients were measured during rectal compliance measurements in 36 patients with fecal incontinence and in 22 control subjects. Anal and rectal pressures were measured simultaneously during the rectal compliance measurements. With standard anal manometry, 75% of patients with fecal incontinence had maximal resting pressure within the normal range, and 39% had maximum squeeze pressure within the normal range. Anorectal pressure gradients did not discriminate better between fecal incontinence and normal anal function, since, depending on the parameters used, 61%–100% of the incontinent patients had anorectal pressure gradients within the normal range. Patients with fecal incontinence had lower rectal volumes than controls at constant defecation urge (median 138 ml and 181 ml, P<0.05) and at maximal tolerable volume (median 185 ml and 217 ml, P<0.05). We conclude that measurements of anorectal pressure gradients offer no advantage over standard anal manometry when comparing patients with fecal incontinence to controls. Patients with fecal incontinence have a lower rectal volume tolerability than control subjects with normal anal function. Accepted: 5 June 1998     

Critical reappraisal of anorectal function tests in patients with faecal incontinence who have failed conservative treatment

Objective

Anorectal function tests are often performed in patients with faecal incontinence who have failed conservative treatment. This study was aimed to establish the additive value of performing anorectal function tests in these patients in selecting them for surgery.

Patients and methods

Between 2003 and 2009, all referred patients with faecal incontinence were assessed by a questionnaire, anorectal manometry and anal endosonography. Patients with diarrhea, inflammatory bowel disease, pouches or rectal carcinoma were excluded.

Results

In total, 218 patients were evaluated. Of these, 107 (49%) patients had no sphincter defects, 71 (33%) had small defects and 40 (18%) had large defects. Anorectal manometry could not differentiate between patients with and without sphincter defects. Patients with sphincter defects were only found to have a significantly shorter sphincter length and reduced rectal capacity compared to patients without sphincter defects. Forty-three patients (20%) had a normal anal pressures ≥40?mmHg. Seventeen patients (8%) had also a dyssynergic pelvic floor both on clinical examination and anorectal manometry. Fifteen patients (7%) had a reduced rectal capacity between 65 and 100?ml. There was no difference in anal pressures or the presence of sphincter defects in these patients compared to patients with a rectal capacity >150?ml. There was no correlation between anorectal manometry, endosonography and faecal incontinence severity scores.

Conclusion

In patients with faecal incontinence who have failed conservative treatment, only anal endosonography can reveal sphincter defects. Anorectal manometry should be reserved for patients eligible for surgery to exclude those with suspected dyssynergic floor or reduced rectal capacity.     

Rectal augmentation and stimulated gracilis anal neosphincter

PURPOSE: The aim of this study was the development of a procedure which would successfully treat selected patients presenting with incapacitating urgency and fecal incontinence. Some patients presenting with urgency and fecal incontinence, with an intact anorectum but deficient sphincter mechanism, have low rectal compliance. Management is problematic, because correction of the sphincter defect does not abolish the incapacitating urgency caused by rectal hypersensitivity. METHODS: This was a prospective study of three female patients with urgency and fecal incontinence who underwent combined rectal augmentation using a segment of distal ileum and stimulated gracilis anal neosphincter. All patients had low rectal volumes and two exhibited a temporal relationship between high-amplitude (>60 mmHg) rectal pressure waves and urgency on prolonged ambulatory anorectal manometry. RESULTS: Urgency was abolished and continence restored in all individuals. When the level of stimulation was not optimal or had been discontinued, patients experienced only passive incontinence with no urgency. Postoperative physiology revealed elevated thresholds to rectal distention and a reduction in the number of high-amplitude rectal pressure waves in all cases. CONCLUSIONS: Combined rectal augmentation with stimulated gracilis anal neosphincter may be of benefit to some patients with distressing urgency and fecal incontinence not previously helped by current techniques.     

Anorectal sphincter function and rectal barostat study in patients following transanal endoscopic microsurgery

BACKGROUND AND AIMS: This study evaluated the effect of transanal endoscopic microsurgery (TEM) on anorectal sphincter functions and determined the risk factors for anorectal dysfunctions (including incontinence). PATIENTS AND METHODS: A study group of 33 patients with small, mobile rectal tumors (adenoma and carcinoma) located up to 12 cm from the anal verge underwent anorectal motility studies (using pull-through anorectal manometry and rectal barostat) and endoanal ultrasound prior to surgery and 3 weeks and 6 months after TEM; controls were 20 healthy volunteers. RESULTS: Resting and squeeze anal pressures were reduced 3 weeks after TEM. Resting anal pressure remained reduced 6 months after surgery; the changes were related to low preoperative levels and to the internal anal sphincter defects rather than to the procedure duration or the type of surgery. High-pressure zone length and vector volume were decreased 3 weeks after TEM and restored 6 months later. Rectoanal inhibitory reflex, reflex sphincter contraction, rectoanal pressure gradients, threshold and maximal tolerable volume of rectal sensitivity, and compliance were significantly changed 3 weeks after TEM; only rectal wall compliance remained low at 6 months. The rectoanal inhibitory reflex, reflex sphincter contraction, rectal sensitivity, and compliance were related to the extent and type of excision (partial or full thickness). Anal ultrasound revealed internal anal sphincter defects in 29% of patients studied 3 weeks after TEM. Only 76% of patients were fully continent. Disturbed anorectal function (including partial fecal incontinence) was observed in up to 50% of patients at 3 weeks. Partial and moderate anorectal dysfunction was found in 21% patients 6 months after surgery. The main risk factors of anorectal dysfunctions following TEM included: postoperative internal anal sphincter defects, low preoperative resting anal pressure, disturbed rectoanal coordination, extent (>50% of wall circumference) and the depth (full thickness) of tumor excision. CONCLUSION: TEM has a relevant but temporary effect on anorectal motility. As a result of TEM procedures 21% of the patients had disturbed anorectal functions, mostly due to the extent or depth of tumor excision (influencing rectal compliance and rectoanal coordination), and to the sphincter defects lowering resting anal pressure. Preoperative anorectal motility studies and anal ultrasound allow the identification of patients with the risk of postoperative anorectal dysfunctions.     

Sensory and motor function in the maintenance of anal continence

Anorectal function was prospectively evaluated in 43 consecutive patients with fecal incontinence and in 19 healthy volunteers using manometry and electrical stimulation of the anoderm. Both anorectal motor and sensory function was impaired in incontinent patients as compared with healthy controls. Further statistical analysis identified four subgroups of patients showing different pathomechanisms of fecal incontinence: severe combined anorectal motor and sensory dysfunction, isolated anal sphincter dysfunction, isolated anorectal sensory dysfunction, and combined dysfunction of the internal anal sphincter and impaired anorectal sensitivity. These data support the hypothesis that sensory function of both the rectum and the anal canal is an important and independent factor in the preservation of continence.     

Rectal tone and compliance affected in patients with fecal incontinence after fistulotomy

AIM: To investigate the anal sphincter and rectal factors that may be involved in fecal incontinence that develops following fistulotomy(FIAF).METHODS: Eleven patients with FIAF were compared with 11 patients with idiopathic fecal incontinence and with 11 asymptomatic healthy subjects(HS). All of the study participants underwent anorectal manometry and a barostat study(rectal sensitivity, tone, compliance and capacity). The mean time since surgery was 28 ± 26 mo. The postoperative continence score was 14 ± 2.5(95%CI: 12.4-15.5, St Mark's fecal incontinence grading system).RESULTS: Compared with the HS, the FIAF patients showed increased rectal tone(42.63 ± 27.69 vs 103.5 ± 51.13, P = 0.002) and less rectal compliance(4.95 ± 3.43 vs 11.77 ± 6.9, P = 0.009). No significant differences were found between the FIAF patients and the HS with respect to the rectal capacity; thresholds for the non-noxious stimuli of first sensation, gas sensation and urge-to-defecate sensation or the noxious stimulus of pain; anal resting pressure or squeeze pressure; or the frequency or percentage of relaxation of the rectoanal inhibitory reflex. No significant differences were found between the FIAF patients and the patients with idiopathic fecal incontinence.CONCLUSION: In patients with FIAF, normal motor anal sphincter function and rectal sensitivity are preserved, but rectal tone and compliance are impaired. The results suggest that FIAF is not due to alterations in rectal sensitivity and that the rectum is more involved than the anal sphincters in the genesis of FIAF.     

Combined anorectal manometry and defecography in 50 consecutive adults with fecal incontinence

Fifty consecutive patients presenting with fecal incontinence were evaluated prospectively with anorectal manometry, defecography, and other tests of anorectal function to assess the clinical utility of defecography in fecal incontinence. Leakage of contrast at rest and failure to narrow the anorectal angle with pelvic squeezing were specific but not sensitive predictors of decreased sphincter pressures as determined by manometry. Thus, after manometry, defecography provided no additional information regarding sphincter strength. Retention of contrast in large rectoceles or incomplete rectal evacuation at defecography had excellent correlation with the presence of clinical symptoms of outlet obstruction constipation (present concurrently with incontinence) and indicated an etiology of outlet obstruction symptoms. Defecography may provide useful information in incontinent patients with outlet obstruction constipation symptoms but has little additive value to anorectal manometry in incontinent patients without such symptoms.     

Endoanal Ultrasound Compared to Anorectal Manometry for the Evaluation of Fecal Incontinence: A Study of the Effect These Tests Have on Clinical Outcome

Tests for evaluating incontinence include endoanal ultrasound (EUS) and anorectal manometry. We hypothesized that EUS would be superior to anorectal manometry in identifying the subset of patients with surgically correctable sphincter defects leading to an improvement in clinical outcome in these patients. The purpose of this study was to compare these 2 techniques to determine which is more predictive of outcome for fecal incontinence. Thirty-five unselected patients with fecal incontinence were prospectively studied with EUS and anorectal manometry to evaluate the internal anal sphincter (IAS) and external anal sphincter (EAS). EUS was performed with Olympus GFUM20 echoendoscope and a hypoechoic defect in the EAS or IAS was considered a positive test. Anorectal manometry was performed with a standard water-perfused catheter system. A peak voluntary squeeze pressure of < 60 mm Hg in women and 120 mm Hg in men was considered a positive test. All patients were administered the Cleveland Clinic Continence Grading Scale at baseline and at follow-up. Improvement in fecal control was defined as a 25% or greater decrease in continence score. EUS versus manometry were compared with subsequent surgical treatment and outcome. P-values were calculated using Fisher's exact test. Patients (n = 32; 31 females) were followed for a mean 25 months (range 13–46). Sixteen patients had improved symptoms (50%). There was no correlation between EUS or anorectal manometry sphincter findings and outcome. Seven of 14 (50%) patients who subsequently underwent surgery versus 9 of 18 (50%) without surgery improved (P = .578). In long-term follow-up, approximately half of patients improve regardless of the results of EUS or anorectal manometry, or whether surgery is performed. Supported in part by a Glaxo-Wellcome Institute for Digestive Health Award.     

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.     

Biofeedback training in patients with fecal incontinence

PURPOSE: This study was undertaken to assess the functional results of biofeedback training in patients with fecal incontinence in relation to clinical presentation and anorectal manometry results. METHODS: Twenty-six consecutive patients with fecal incontinence were treated with biofeedback training using anorectal manometry pressure for visual feedback. Ten patients had passive incontinence only, six patients had urge incontinence, and ten patients had combined passive and urge incontinence. RESULTS: Patients with urge incontinence had a lower maximum voluntary contraction pressure (92 ± 12 mmHg) and lower maximum tolerable volume (78 ± 13 ml) than patients with passive incontinence (140 ± 43 mmHg and 166 ± 73 ml). Twenty-two patients completed the treatment, five patients (23 percent) showed excellent improvement, nine patients (41 percent) had good results, and eight (36 percent) patients showed no improvement. At follow-up on average of 21 months after therapy, 41 percent of our patients reported continued improvement. The maximum tolerable volume was higher in those with excellent (140.4 ± 6.8 ml) or good (156.3 ± 6.64 ml) results of therapy than it was in those with poor results (88.5 ± 2.5 ml). Greater asymmetry of the anal sphincter also correlated to poor results. CONCLUSION: Biofeedback therapy improved continence immediately after training and at follow-up after 21 months, but the initial results were better. The urge fecal incontinence seems to be related to function of the external anal sphincter and to the maximum tolerable volume. Low maximum tolerable volume and anal sphincter asymmetry were associated with a poor outcome of therapy     

Therapie der Stuhlinkontinenz bei älteren Patienten: Untersuchung zur Wirksamkeit eines Biofeedback-Heimtrainingsprogramms

The increased prevalence of urinary and fecal incontinence is one of the most important factors in the loss of independence and mobility in the elderly population. It is also one of the major reasons for elderly people to give up their household and move into a nursing home. Anorectal biofeedback therapy is a very effective treatment for fecal incontinence. However, due to the increased immobility of elderly people, ambulatory biofeedback training programs which require the participants to leave their homes and travel to the next available outpatient clinic on a regular basis, especially when depending on public transportation, may prove particularly difficult for elderly, incontinent subjects. Supervised home biofeedback training programs may offer an alternative for those patients, who are motivated enough and not mentally impaired. Two different age groups of women (between 49 and 63; and between 65 and 78 years old) suffering from fecal incontinence due to external anal sphincter impairment, received a supervised home biofeedback program, after extensive anorectal diagnostics including manometry. The program focused on improving voluntary sphincter contraction. After an average of 9 months, anorectal manometry was repeated, and anal resting and squeeze pressure as well as minimal rectal perception threshold were determined. There was no effect on anal resting pressure and rectal perception. However, anal maximum squeeze pressure as well as squeeze pressure over 10 s was substantially increased with no difference between the age groups. CONCLUSION: Supervised home biofeedback for sphincter insufficiency was effective in improving the voluntary contraction of the anorectum in both age groups. Therefore, biofeedback home training programs may offer an alternative to ambulatory programs for those individuals, who are not mobile enough to regularly attend an outpatient clinic.     

Update of tests of colon and rectal structure and function

This review deals with the indications, methods, strengths, and limitations of anorectal testing in clinical practice. In chronic constipation, anal manometry and a rectal balloon expulsion test, occasionally supplemented by defecography, are useful to identify a functional defecatory disorder, because symptoms may respond to pelvic floor retraining. In patients with fecal incontinence, diagnostic testing complements the clinical assessment for evaluating the pathophysiology and guiding management. Manometry measures anal resting and squeeze pressures, which predominantly reflect internal and external anal sphincter function, respectively. Defecation may be indirectly assessed by measuring the recto-anal pressure gradient during straining and by the rectal balloon expulsion test. Endoanal ultrasound and magnetic resonance imaging (MRI) can identify anal sphincter structural pathology, which may be clinically occult, and/or amenable to surgical repair. Only MRI can identify external sphincter atrophy, whereas ultrasound is more sensitive for internal sphincter imaging. By characterizing rectal evacuation and puborectalis contraction, barium defecography may demonstrate an evacuation disorder, excessive perineal descent or a rectocele. Dynamic MRI can provide similar information and also image the bladder and genital organs without radiation exposure. Because the measurement of pudendal nerve latencies suffers from several limitations, anal sphincter electromyography is recommended when neurogenic sphincter weakness is suspected.     

The efficacy and adverse effects of topical phenylephrine for anal incontinence after low anterior resection in patients with rectal cancer

Background Anal incontinence is experienced by some patients with rectal cancer who received low anterior resection. This study was to examine the efficacy and adverse effects of the alpha-1 adrenergic agonist phenylephrine, which causes contraction of the internal anal sphincter and raises the resting pressure in these patients. Patients and methods Thirty-five patients with anal incontinence were treated with 30% phenylephrine or a placebo randomly allocated in a double-blind study. The efficacy of the drug was assessed by changes in the following standardized questionnaire scores: the fecal incontinence severity index (FISI), fecal incontinence quality of life (FIQL) scales, and a global efficacy question. Anal sphincter function was evaluated using anorectal manometry. Results Phenylephrine did not improve either the FISI score or any of the four FIQL scores. Five of 17 (29%) patients reported subjective improvement after phenylephrine compared with 4 of 12 (33%) using the placebo. The maximum resting anal pressure did not differ between baseline and after 4 weeks application of phenylephrine (30.0 to 27.3 mmHg). In the phenylephrine group, allergic dermatitis was developed in five patients and headache in two. Conclusion In the patients with anal incontinence after low anterior resection for rectal cancer, phenylephrine gel did not seem to be helpful in relieving symptoms with some adverse effects.     

Are special investigations of value in the management of patients with fecal incontinence?

PURPOSE: The aim of this study was to determine whether special investigations significantly alter either the diagnosis or the management plan of patients with fecal incontinence assessed on the basis of a structured history and physical examination alone. METHODS: Fifty consecutive patients with fecal incontinence were prospectively studied in a tertiary referral clinic. Each patient was assessed by two clinicians who independently formulated a diagnosis and treatment plan based on the history and physical examination. The resulting 100 patient assessments were then compared with the final diagnosis and treatment plan formulated on completion of endoanal ultrasound, anal manometry, external sphincter electromyography, and defecating proctography. RESULTS: In the assessment of fecal incontinence, the addition of special investigations altered the diagnosis of the cause of incontinence based on history and examination alone in 19 percent of cases. The management plan was altered in 16 percent of cases. Special investigations were most useful in separating neuropathy from rectal wall disorders and in demonstrating the unexpected presence of internal sphincter defects and neuropathy. CONCLUSIONS: Even experienced colorectal surgeons will misdiagnose up to one-fifth of patients presenting with fecal incontinence if assessment is based on the history and physical examination alone. However surgically correctable causes of incontinence are rarely missed on clinical assessment.     

Anorectal manometry and defecography in the diagnosis of fecal incontinence.

We carried out anorectal manometry and defecography prospectively in 43 consecutive patients with fecal incontinence. A subgroup of 17 patients with severe incontinence was identified radiologically by a short and incompletely closed anal canal. In these patients, the anal resting pressure was significantly lower than in the rest of the group (34.9 +/- 11.4 mm Hg versus 60.0 +/- 25.7 mm Hg, respectively; p less than 0.01). The anorectal angle did not change in 24 patients during squeezing, indicating a dysfunction of the puborectalis muscle. Manometric data did not differ between this subgroup and patients with a more acute anorectal angle during voluntary sphincter contraction. This indicates that the anal pressures recorded manometrically do not reflect the function of a muscular component that is important in the maintenance of fecal continence. We conclude that anorectal manometry and defecography are complementary diagnostic tools in the investigation of patients with fecal incontinence.     

Defecation disorders. Characteristics of manometric studies and rehabilitation

The authors review the literature and their personal experience about the systematic exploration of defecation disorders by anorectal manometry and colpocystodefecography. They stress the importance of combining functional and morphological evaluation, in order to avoid inappropriate surgery. Concerning anorectal manometry, the determination of the smallest volume of rectal distention inducing a complete relaxation of the internal anal sphincter was found more useful than the maximal tolerable volume in the exploration of defecation disorders. Finally, the authors report the results of biofeedback conditioning prescribed in 30 patients (27 women, 3 men, mean age: 55 years) with defecation disorders (terminal constipation in 21, fecal incontinence in 9 patients). Several characteristics of anorectal manometry and of defecography were significantly improved after biofeedback conditioning.