Impaired rectal sensation in idiopathic faecal incontinence

In 15 patients suffering from idiopathic faecal incontinence and in 15 matched controls, manometric studies of anorectal pressure and studies of the rectoanal reflex and rectal sensitivity were carried out. Patients with idiopathic faecal incontinence had normal resting pressure but reduced squeeze and stress pressures; the anal sphincter relaxed before a sensation of rectal distension occurred. The conclusion is that both reduced voluntary muscle contraction and impairment of rectal sensation are conducive to soiling in idiopathic faecal incontinence.     

Abnormal visceral autonomic innervation in neurogenic faecal incontinence.

Changes of denervation in the anal sphincter striated and smooth muscle in patients with neurogenic faecal incontinence are well established. This study aimed to determine if there is also a more proximal visceral autonomic abnormality. Thirty women with purely neurogenic faecal incontinence (prolonged pudendal nerve latencies and an intact sphincter ring) and 12 patients with neuropathic changes together with an anatomical disruption were studied. Two control groups consisted of 18 healthy volunteer women and 17 women with normal innervation but an anatomically disrupted sphincter. Rectal sensation was assessed using balloon distension and electrical mucosal stimulation, and anal sensation by electrical stimulation. Rectal compliance was studied to determine whether sensory changes were primary or caused by altered rectal wall viscoelastic properties. Anal canal pressure changes in response to both rectal distension and rectal electrical stimulation were measured to assess the intrinsic innervation of the internal anal sphincter. Patients with neurogenic incontinence alone had impaired rectal sensation to distension (53.1 v 31.5 ml, p < 0.05, neurogenic v controls) and to electrical stimulation (24.4 v 14.8 mA, p < 0.005). Patients with neurogenic incontinence and sphincter disruption also showed impaired sensation compared with healthy controls (55.8 ml v 31.5 ml, p < 0.05 and 22.9 mA v 14.8 mA, p < 0.05). Patients with only a disrupted sphincter had normal visceral sensation to both types of testing. Both rectal compliance and the response of the internal anal sphincter to rectal distension and electrical stimulation were normal in all patient groups. This study suggests that there is a visceral sensory abnormality in patients with neurogenic incontinence which is not caused by altered rectal compliance. As evaluated in this study the intrinsic innervation of the internal anal sphincter is not affected in this process.     

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.     

Relationship between symptoms and disordered continence mechanisms in women with idiopathic faecal incontinence

BACKGROUND AND AIMS: Anal sphincter weakness and rectal sensory disturbances contribute to faecal incontinence (FI). Our aims were to investigate the relationship between symptoms, risk factors, and disordered anorectal and pelvic floor functions in FI. METHODS: In 52 women with "idiopathic" FI and 21 age matched asymptomatic women, we assessed symptoms by standardised questionnaire, anal pressures by manometry, anal sphincter appearance by endoanal ultrasound and magnetic resonance imaging (MRI), pelvic floor motion by dynamic MRI, and rectal compliance and sensation by a barostat. RESULTS: The prevalence of anal sphincter injury (by imaging), reduced anal resting pressure (35% of FI), and reduced squeeze pressures (73% of FI) was higher in FI compared with controls. Puborectalis atrophy (by MRI) was associated (p<0.05) with FI and with impaired anorectal motion during pelvic floor contraction. Volume and pressure thresholds for the desire to defecate were lower, indicating rectal hypersensitivity, in FI. The rectal volume at maximum tolerated pressure (that is, rectal capacity) was reduced in 25% of FI; this volume was associated with the symptom of urge FI (p<0.01) and rectal hypersensitivity (p = 0.02). A combination of predictors (age, body mass index, symptoms, obstetric history, and anal sphincter appearance) explained a substantial proportion of the interindividual variation in anal squeeze pressure (45%) and rectal capacity (35%). CONCLUSIONS: Idiopathic FI in women is a multifactorial disorder resulting from one or more of the following: a disordered pelvic barrier (anal sphincters and puborectalis), or rectal capacity or sensation.     

Effect of aging on anorectal function.

Measurements of anorectal function were conducted on 37 elderly (66-87 years) and 48 young (19-55 years) normal subjects. Elderly subjects had decreased anal pressures compared with younger subjects, required lower rectal volumes to inhibit anal sphincter tone and had increased rectal pressures upon balloon distension. The rectal volume required to cause the desire to defecate and the maximum tolerated volume were lower in the elderly, but the corresponding rectal pressures were similar, indicating the sensations were mediated by tension, or pressure receptors. Rectal contractions were generated at similar degrees of rectal distension. A lower proportion of elderly, compared with young subjects could defecate a sphere 18 mm in diameter within 20 seconds. The degree of perineal descent was greater in the elderly female subjects compared with the young women, although there was no difference in this measurement between men. The anorectal angle was similar in young and old. The changes in anorectal function in the elderly would tend to make them more susceptible to faecal incontinence.     

General geriatrics and gastroenterology: constipation and faecal incontinence

The incidence of constipation increases with age but no consistent changes of colonic or anorectal motility have been shown in elderly people. Instead, neurological diseases, constipating drugs, bedriddenness and weak straining ability may explain this increased prevalence of constipation. The amount of dietary fibre in the diet may be reduced because of poor chewing ability. Parkinson's disease is accompanied by both slow colonic transit and impaired relaxation of the anal sphincter. Drug-induced constipation is particularly likely with anti-parkinsonism drugs (either anti-cholinergic or dopaminergic) and also with tricyclic anti-depressants, opiates, iron, anti-convulsants and aluminium- or calcium-containing antacids. The prevalence of faecal incontinence is also increased in elderly people. About half of frail bedridden institutionalized patients are incontinent. Anal sphincter pressures tend to be lower, but variables of sensitivity are not. In bedridden people faecal impaction may occur. The ensuing rectal distension leads to relaxation of the internal sphincter and hence to faecal soiling. The condition is often overlooked though correct diagnosis is rather simple, being made with a digital rectal examination.     

Efficacy of biofeedback training in improving faecal incontinence and anorectal physiologic function.

The efficacy of biofeedback treatment on faecal incontinence and anorectal function was evaluated in eight patients with faecal incontinence treated with biofeedback training and medical therapy. Outcome and anorectal function were compared with nine faecal incontinent patients who received medical therapy alone. Three month follow up showed that 50% of patients in the biofeedback plus conventional treatment group and 56% of those treated conventionally only had improved. One year follow up showed that 13% in the biofeedback group were free of soiling and an additional 25% had improved. The results were similar in the conventionally treated group--11% were free of soiling and an additional 44% improved. Anal pressures at rest and squeeze, the rectal distension volume that induced sustained inhibition of both the external and internal anal sphincter, and continence to rectally infused saline were significantly reduced in both groups of patients compared with controls (p less than 0.05). Biofeedback treatment had no effect on these abnormal anorectal functions in either patients who improved or those who did not. The improvement in faecal incontinence was probably due to medical intervention or regression of symptoms with time, or both, and not the result of biofeedback training.     

Pelvic floor neuropathy: a comparative study of diabetes mellitus and idiopathic faecal incontinence.

Twenty one patients with diabetic peripheral neuropathy, 18 with idiopathic faecal incontinence and 11 normal controls were studied with techniques of mucosal electrosensitivity, rectal distension for the quantitative assessment of anorectal sensation, and manometric and electromyographic tests for the assessment of anorectal motor function. An asymptomatic sensorimotor deficit was found in the anal canal of patients with diabetic peripheral neuropathy. Mucosal electrosensitivity thresholds in the anal canal were significantly higher (p less than 0.01 v controls) and fibre density of the external anal sphincter significantly raised (p less than 0.0001 v controls). Anal manometry and pudendal nerve terminal motor latencies were similar to controls. In patients with idiopathic faecal incontinence the tests of sensory and motor function also showed a sensorimotor neuropathy; compared with controls, mucosal electrosensitivity thresholds were significantly higher (p less than 0.002), anal canal resting and maximum squeeze pressures were significantly lower (p less than 0.05 and p less than 0.002 respectively), and pudendal nerve terminal motor latencies and fibre density of the external anal sphincter were significantly raised (both p less than 0.05). Sensory thresholds to rectal distension were similar in all groups. Pelvic floor sensorimotor neuropathy in diabetic patients has several features in common with that of patients with idiopathic faecal incontinence but its functional significance remains uncertain.     

Anorectal function in elderly patients with fecal impaction

Manometric and other investigations were carried out in 55 elderly patients who had impacted masses of feces in the rectum upon admission to hospital and in 36 elderly age- and sex-matched control subjects. Maximum basal and maximum squeeze sphincter pressures in the patients were similar to those in the elderly controls. Most elderly patients in the impacted group and all control subjects were able to pass a 50-ml balloon from the rectum, although a lower proportion of patients, admitted with impaction, could expel a small solid sphere. In patients the rectum had to be distended with larger volumes than in controls before the presence of the rectal balloon, pain, and the desire to defecate were perceived and before rectal contractions were generated. Rectal pressures, recorded during rectal distention, were lower in the impacted group than in the control group. Finally, anal and perianal sensation was impaired in patients with fecal impaction. These findings are similar to those described in patients with low spinal cord injuries.     

Impaired internal anal sphincter in a subgroup of patients with idiopathic fecal incontinence

During multiport manometric recordings of the anorectum, 35 of 140 patients with idiopathic fecal incontinence had abnormally weak sphincters that did not relax during rectal distention, suggesting impaired function of the internal anal sphincter. This study documents this finding and compares anorectal function in these 35 patients with 25 matched normal subjects and the remaining 105 incontinent patients. Basal and squeeze pressures were significantly lower in the incontinent study group than in the other two groups. During rectal distention, 25 of 35 patients showed no anal relaxation at any volume, whereas 10 patients showed some relaxation after 60-ml distention because of the postinflation rebound in internal anal sphincter tone. The electrical responses of the external anal sphincter to rectal distention and to increases in intraabdominal pressure were greater in patients than in normal subjects, but the anal pressures were lower and anal leakage was common. Rectal sensations were not significantly different from normal subjects. These results indicate that 25% of patients with idiopathic fecal incontinence have markedly impaired function of the internal anal sphincter, but these patients also have extremely weak external sphincters.     

Combined sensory and motor deficit in primary neuropathic faecal incontinence.

Eleven patients with idiopathic faecal incontinence (IFI) and nine normal controls were studied with techniques of mucosal electrosensitivity and rectal distention for the quantitative assessment of anal and rectal sensation and with manometric and electromyographic tests for the assessment of anorectal motor function. The tests of motor function showed pelvic floor motor neuropathy in the patients with IFI, compared with controls, anal canal resting and voluntary contraction pressures were significantly (p less than 0.05, p less than 0.002) lower, pudendal nerve terminal motor latency and external anal sphincter fibre density were significantly (p less than 0.05, p less than 0.05) raised. The results of mucosal electrosensitivity (MES) disclosed a sensory deficit in the anal canal in patients with IFI, compared with controls, MES threshold was significantly (p less than 0.002) higher. Sensory thresholds to rectal distension were similar in the two groups. This study shows that sensory deficit of the anal canal occurs in combination with the motor neuropathy of the anal canal musculature in primary neuropathic faecal incontinence.     

Relation between rectal sensation and anal function in normal subjects and patients with faecal incontinence.

The relation between sensory perception of rapid balloon distension of the rectum and the motor responses of the rectum and external and internal anal sphincters in 27 normal subjects and 16 patients with faecal incontinence who had impaired rectal sensation but normal sphincter pressures was studied. In both patients and normal subjects, the onset and duration of rectal sensation correlated closely with the external anal sphincter electrical activity (r = 0.8, p less than 0.0001) and with rectal contraction (r = 0.51, p less than 0.001), but not with internal sphincter relaxation. All normal subjects perceived a rectal sensation within one second of rapid inflation of a rectal balloon with volumes of 20 ml or less air. Six patients did not perceive any rectal sensation until 60 ml had been introduced, while in the remaining nine patients the sensation was delayed by at least two seconds. Internal sphincter relaxation occurred before the sensation was perceived in three of 27 normal subjects and 11 of 16 patients (p less than 0.001), and could be associated with anal leakage, which stopped as soon as sensation was perceived. The lowest rectal volumes required to induce anal relaxation, to cause sustained relaxation, or to elicit sensations of a desire to defecate or pain were similar in patients and normal subjects. In conclusion, these results show the close association between rectal sensation and external anal sphincter contraction, and show that faecal incontinence may occur as a result of delayed or absent external anal sphincter contraction when the internal anal sphincter is relaxed.     

What affects continence after anterior resection of the rectum?

Functional results after anterior rectal resections are commonly considered satisfactory but variable percentages of postoperative incontinence are often reported. Continence was evaluated after 20 low anterior resections (LAR) and 13 high anterior resections (HAR) by means of clinical assessment, anorectal manometry, and evacuation proctography. Whereas all HAR patients had perfect continence, 10 patients (50 percent of the LAR group had occasional episodes of soiling from liquid feces, 5 patients (25 percent had frequent soiling or occasional incontinence for solid feces, and 1 patient (5 percent had frequent solid stool loss requiring surgical treatment. Anal canal resting pressure at 3 and 4 cm from the anal verge was significantly lower in the LAR group (P<0.02 and P<0.05, respectively) than in the HAR group. However, the maximum voluntary contraction did not differ between the two groups. Rectoanal inhibitory reflex was found to be present in 17 of the 20 patients with LAR and in all patients with HAR. The volume at which the anal sphincter is continuously inhibited was significantly reduced in the LAR group (P<0.001). Also, the conscious rectal sensibility volumes were found to be significantly reduced for threshold, constant, and maximum tolerated volume. Threshold volume for internal sphincter relaxation was lower than the threshold volume for rectal sensation in some patients with LAR. This could allow postoperative fecal soiling. Rectal compliance was decreased (P<0.001) in the LAR group. Evacuation proctography, performed in six LAR patients affected by major soiling or solid stool loss, revealed an abnormal obtuse anorectal angle and pathologic lowering of the perineum at rest and during defecation. The concomitance of internal anal sphincter impairment, reduction in rectal compliance, and previous pelvic floor muscle damage are postulated as cause affecting continence in patients who underwent LAR.Read at the Congress on Colo-Rectal Disease Milan, Italy, June 29–30, 1989.     

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.     

Anal incontinence in patients with Addison's disease: a gluco- and mineralocorticoid independent sphincter malfunction?]

Anorectal motor function was evaluated in 15 female patients with Addison's disease and androgen deficiency and 15 age-matched healthy volunteers. Medical history revealed symptoms of faecal incontinence in 5 patients. The patients showed decreased maximum retention volumes (p less than 0.01) in the rectal saline infusion test. Lowered anal sphincter resting (p less than 0.01) and squeeze pressure (p less than 0.01) was demonstrated in patients with adrenocortical insufficiency. No differences between patients and controls were found in respect of perception volume, minimal distension volume for sphincter relaxation and rectal compliance by means of intrarectal balloon distension. Electromyography of the external anal sphincter was performed in 8 patients and showed no evidence for a neurogenic defect. Relevant morphological changes of the anorectum could be excluded endoscopically in 13 of the 15 patients. Therefore impaired anorectal muscular function is responsible for faecal incontinence in patients with Addison's disease and androgen deficiency. Further investigations will show, whether these findings are the consequence of lowered androgen production.     

Anorectal manometry in patients with chronic constipation: a single-center experience

BACKGROUND/AIMS: Constipation is a common complaint, but its clinical presentation varies with each individual. The aim of this study was to evaluate anorectal physiology in a prospective group of patients with chronic constipation. METHODOLOGY: A total of 24 consecutive patients with constipation underwent solid-state anorectal manometry. Fifteen healthy controls were also studied. The anorectal parameters included resting and squeeze sphincter pressure, sensory thresholds in response to balloon distension, compliance of rectum, and rectoanal inhibitory reflex (RAIR). RESULTS: The rectal sensitivity for urge and pain did not differ between the groups, but the threshold volume for first sensation was higher in patients with constipation (p < 0.05). There was no group difference in the volume threshold for RAIR. However, the prevalence of impaired RAIR was higher in constipated patients. Anal pressure was lower in patients for maximal squeeze (p < 0.05). There was a positive correlation between the anal sphincter length and resting pressure in patients (r = 0.51, p = 0.03) and healthy controls (r = 0.72, p = 0.01). CONCLUSIONS: Constipated patients are characterized by impaired rectal sensitivity and decreased anal sphincter contractile pressure. Anorectal manometry is helpful for diagnosing anorectal dysfunction in patients with chronic constipation.     

Anorectal sensory and motor function in neurogenic fecal incontinence. Comparison between multiple sclerosis and diabetes mellitus

We measured anorectal sensory and motor function in 11 patients with multiple sclerosis and fecal incontinence, 11 continent patients with multiple sclerosis, 10 diabetics with fecal incontinence, and 12 healthy control subjects. The threshold volume at which patients with multiple sclerosis and fecal incontinence experienced rectal sensation was higher than that in healthy controls (42.7 +/- 6.2 mL vs. 13.3 +/- 2.8 mL; P less than 0.01) and was similar to that in incontinent diabetics (36.5 +/- 5.7 mL). Patients with multiple sclerosis and incontinent diabetics also showed increased thresholds of phasic external sphincter contraction compared with controls (P less than 0.05). Diabetics with incontinence had reduced resting and maximal voluntary anal sphincter pressures compared with controls (P less than 0.05), whereas patients with multiple sclerosis and incontinence showed only decreased maximal voluntary anal sphincter pressures (P less than 0.01 vs. controls and diabetics). Incontinent patients with multiple sclerosis also required smaller volumes of rectal distention to inhibit internal sphincter tone compared with diabetics and controls (P less than 0.01). Decreased maximal voluntary squeeze pressures were less severe in continent patients with multiple sclerosis than in incontinent patients with multiple sclerosis. We conclude that impaired function of the external anal sphincter and decreased volumes of rectal distention to inhibit the internal anal sphincter or both may contribute to fecal incontinence in multiple sclerosis. In addition, increased thresholds of conscious rectal sensation in some incontinent patients with multiple sclerosis and diabetes mellitus may contribute to fecal incontinence by impairing the recognition of impending defecation.     

Anal function in geriatric patients with faecal incontinence.

The association of faecal incontinence with constipation and confusion in the elderly is well recognised but the anal function of faecally incontinent geriatric patients is poorly understood. Anal studies were therefore performed on 99 geriatric patients (49 with faecal incontinence, 19 continent patients with faecal impaction and 31 geriatric control patients with normal bowel habit) and 57 younger healthy control patients. An age related reduction in anal squeeze pressure but not resting pressure was identified. A reduction in anal resting pressure was detected in the faecally incontinent geriatric patients but squeeze pressure did not differ significantly from that found in the other geriatric patients. Anal sensation was impaired in the faecally incontinent patients. No difference was found between the groups as measured by pudendal nerve terminal motor latency. Gross neuropathy of the distal part of the pudendal nerve does not account for the observed external anal sphincter weakness in geriatric patients or for their faecal incontinence. Internal anal sphincter dysfunction is an important factor in faecal incontinence in the elderly.     

Paradoxical high anal resting pressures in men with idiopathic fecal seepage

PURPOSE: Fecal incontinence has been a matter of concern for many years, but seepage is poorly understood, especially in men. METHODS: We compared the results of anorectal physiologic tests in a group of 16 male patients who complained of fecal soiling but had no previous history of anorectal surgery or disease and had normal clinical examinations with findings of 16 normal male controls. Physical examination and proctosigmoidoscopy were normal in each patient. RESULTS: Maximum anal resting pressure (median interquartile range) was 136 (120–145) cm H₂O in the “seepage” group and 104 (83–112) cm H₂O in controls (P<0.01). Inflation volumes at which patients and controls experienced rectal sensation were 45 (35–80) and 90 (75–100) ml of air, respectively (P<0.01). Maximum tolerated volumess in the rectum were 130 (85–180) ml of air in the seepage group and 190 (140–240) ml of air in controls (P<0.01). Median length of the anal sphincter was 3.75 (3.5–4) cm in patients and 3 (3–3.5) cm in controls (P<0.01). Maximum squeeze pressures, sensation in the anal canal, and sphincter relaxation in response to rectal distention were similar in the two groups. CONCLUSION: Male patients with “idiopathic” fecal seepage have a long anal sphincter with abnormally high resting tone.     

A prospective non-randomized two-centre study of patients with passive faecal incontinence after birth trauma and patients with soiling after anal surgery, treated by elastomer implants versus rectal irrigation

Aim

This study is a prospective evaluation of patients with passive faecal incontinence and patients with soiling treated by elastomer implants and rectal irrigation.

Patients and methods

Patients with passive faecal incontinence after birth trauma resulting from a defect of the internal sphincter and patients with soiling after previous anal surgery were included. All patients underwent endo-anal ultrasound, magnetic resonance imaging, and anal manometry. The patients with passive faecal incontinence were initially treated by anal sphincter exercises and biofeedback therapy during half a year. The patients completed incontinence scores, a quality of life questionnaire, and a 2-week diary card.

Results

The elastomer group consisted of 30 males and 45 females with a mean age of 53?years (25–77). The rectal irrigation group consisted of 32 males and 43 females with a mean age of 50?years (25–74). At 6?months follow-up, 30 patients with soiling of the rectal irrigation group and only nine patients of the elastomer group were completely cured (p?=?0.02). Only three patients with passive faecal incontinence were cured in the rectal irrigation group and none in the elastomer group. Three distal migrations of elastomer implants required removal at follow-up.

Conclusions

After patients had performed anal sphincter exercises, no clear improvement of passive faecal incontinence was obtained by elastomer implants or rectal irrigation. However, rectal irrigation is far more effective than elastomer implants in patients with soiling.