Anorectal pressure gradient in patients with anal incontinence

Anorectal pressures in patients with fecal incontinence have been investigated. With anal manometry, 34 percent of patients with fecal incontinence had maximal resting pressure and 39 percent had maximal squeeze pressure within the normal range. When a pressure gradient was calculated as the pressure difference between maximal resting pressure and rectal pressuring during filling of a rectal balloon, patients with fecal incontinence could be better distinguished from controls: 20 percent of patients with fecal incontinence had values within the normal range when the rectal pressure at the earliest defecation urge was used (P <0.05), and 12 percent had values within the normal range when the rectal pressure at maximal tolerable volume was used (P <0.01). Anorectal pressure gradient measurements seem to distinguish patients with fecal incontinence from controls better than maximal resting pressure or maximal squeeze pressure alone.     

Rectal compliance as a routine measurement

PURPOSE: The clinical impact of rectal compliance and sensitivity measurement is not clear. The aim of this study was to measure the rectal compliance in different patient groups compared with controls and to establish the clinical effect of rectal compliance. METHODS: Anorectal function tests were performed in 974 consecutive patients (284 men). Normal values were obtained from 24 controls. Rectal compliance measurement was performed by filling a latex rectal balloon with water at a rate of 60 ml per minute. Volume and intraballoon pressure were measured. Volume and pressure at three sensitivity thresholds were recorded for analysis: first sensation, urge, and maximal toleration. At maximal toleration, the rectal compliance (volume/pressure) was calculated. Proctoscopy, anal manometry, anal mucosal sensitivity, and anal endosonography were also performed as part of our anorectal function tests. RESULTS: No effect of age or gender was observed in either controls or patients. Patients with fecal incontinence had a higher volume at first sensation and a higher pressure at maximal toleration (P=0.03), the presence of a sphincter defect or low or normal anal pressures made no difference. Patients with constipation had a larger volume at first sensation and urge (P<0.0001 andP<0.01). Patients with a rectocele had a larger volume at first sensation (P=0.004). Patients with rectal prolapse did not differ from controls; after rectopexy, rectal compliance decreased (P<0.0003). Patients with inflammatory bowel disease had a lower rectal compliance, most pronounced in active proctitis (P=0.003). Patients with ileoanal pouches also had a lower compliance (P<0.0001). In the 17 patients where a maximal toleration volume<60 ml was found, 11 had complaints of fecal incontinence, and 6 had a stoma. In 31 patients a maximal toleration volume between 60 and 100 ml was found; 12 patients had complaints of fecal incontinence, and 6 had a stoma. Proctitis or pouchitis was the main cause for a small compliance. All 29 patients who had a maximal toleration volume>500 ml had complaints of constipation. No correlation between rectal and anal mucosal sensitivity was found. CONCLUSION: Rectal compliance measurement with a latex balloon is easily feasible. In this series of 974 patients, some patient groups showed an abnormal rectal visceral sensitivity and compliance, but there was an overlap with controls. Rectal compliance measurement gave a good clinical impression about the contribution of the rectum to the anorectal problem. Patients with proctitis and pouchitis had the smallest rectal compliance. A maximal toleration volume<60 ml always led to fecal incontinence, and stomas should be considered for such patients. A maximal toleration volume>500 ml was only seen in constipated patients, and therapy should be given to prevent further damage to the pelvic floor. Values close to or within the normal range rule out the rectum as an important factor in the anorectal problem of the patient.Drs. Sloots and Poen were supported by a grant from Janssen-Cilag. Presented at the meeting of the Dutch Society of Gastroenterology, Veldhoven, the Netherlands, October 7 to 8, 1999.     

Dynamic anal manometry: physiological variations and pathophysiological findings in fecal incontinence.

A recently developed technique for dynamic anal manometry was used to study 40 healthy volunteers and 23 patients with fecal incontinence. Seven parameters of anal function were measured. Intraindividual variation of the parameters was studied in 5 females and 5 males. The results of dynamic anal manometry were compared with standard pull-through static anal manometry and correlated well. During opening of the anal sphincter at rest, compliance increased with increasing distension. Males had higher maximal closing pressures during squeeze and lower anal compliance during squeeze than females. There was no sex differences of the sphincter measurements at rest. Age had little effect, and gender had no effect on the measurements. With standard anal manometry, 6 of 23 patients with fecal incontinence both had maximal resting pressure and maximal squeeze pressure within the normal range. When dynamic anal manometry was used, all 23 patients showed one or more abnormal values. The method of dynamic anal manometry provides an opportunity for a more thorough assessment of anal sphincter function than previous manometric methods.     

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.     

Rectal compliance in the assessment of patients with fecal incontinence

Rectal compliance (dV/dP) was studied in 31 patients with fecal incontinence, 8 patients with constipation, and 16 control subjects. Patients with fecal incontinence experienced a constant defecation urge at a lower rectal volume and also had a lower maximal tolerable volume and a lower rectal compliance than control subjects (median 126 vs. 155 ml, 170 vs. 220 ml, and 9 vs. 15 ml/mm Hg, respectively;tP <0.05). Constipated patients had a higher constant defecation urge volume and maximal tolerable volume than controls (median, 266 ml and 300 ml;P <0.05). There was no differences in the parameters between patients with idiopathic fecal incontinence and patients with incontinence of traumatic origin, indicating that a poorly compliant rectum in patients with fecal incontinence may be secondary to anal incontinence due to the lack of normal reservoir function.Reprints will not be available.     

Functional changes after physiotherapy in fecal incontinence

Background Physiotherapy is a common treatment option in patients with fecal incontinence. Although physiotherapy may result in relief of symptoms, to what extent improvement is associated with changes in anorectal function is still unclear.Aim The aim of the present study was to investigate prospectively how anorectal function changes with physiotherapy and whether these changes are related to changes in fecal incontinence score.Methods Consenting consecutive patients (n=266) with fecal incontinence (91% women; mean age, 59 years) underwent anorectal manometry, anal and rectal mucosal sensitivity measurements, and rectal capacity measurement at baseline and after nine sessions of standardized pelvic floor physiotherapy. These findings were compared with changes in Vaizey incontinence score.Results On follow-up 3 months after physiotherapy, squeeze pressure (p=0.028), as well as urge sensation threshold (p=0.046) and maximum tolerable volume (p=0.018), had increased significantly. The extent of improvement was not related to age, duration of fecal incontinence, menopause, and endosonography findings. All other anorectal functions did not change. An improvement in the Vaizey score was moderately correlated with an increase in incremental squeeze pressure (r=0.14, p=0.04) and a decrease in anal mucosal sensitivity threshold (r=0.20, p=0.01).Conclusions Physiotherapy improves squeeze pressure, urge sensation, and maximum tolerable volume. However, improved anorectal function does not always result in a decrease in fecal incontinence complaints.     

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.     

Evaluation of anorectal physiology in patients with increased mast cells

Diarrhea, urgency, and fecal incontinence are common complaints in systemic mastocytosis and in patients with increased gastrointestinal mucosal mast cells. We performed anorectal manometry on six patients with clinical symptoms of mastocytosis and histologic evidence of increased mast cells and compared the results to anorectal manometry of six age-and sex-matched controls, with no bowel symptoms. Standard techniques with balloon volumes were used to measure maximal basal pressure, maximal squeeze pressure, smallest volume sensed, degree of relaxation of the internal sphincter, and the volume causing: (1) a strong urge to defecate and (2) pain. Patients with mastocytosis, compared with controls, had smaller balloon volumes induce rectal urgency (97 vs 164 ml) and pain (117 vs 278 ml). A trend was present for lower maximal basal pressure in mastocytosis, but was not statistically significant. Sensitivity to balloon inflation suggests decreased rectal compliance or overreactive rectal, contractility. These findings provide an explanation for the anorectal symptoms in patients with increased mast cells.     

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.     

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.     

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.     

Rectal compliance, capacity, and rectoanal sensation in fecal incontinence

OBJECTIVE: Assessments of the pathophysiology of fecal incontinence are skewed toward anal sphincter function; however, rectal compliance, rectoanal sensation and capacity may also be relevant. The aim of this study was to evaluate the usual and some novel diagnostic approaches in fecal incontinence. METHODS: In 22 unselected patients with fecal incontinence (21 F, 33-75 yr), we quantified: 1) symptoms, anorectal manometry, and anal ultrasound; 2) anal perception of temperature and light touch; 3) rectal sensitivity and compliance to distension; and 4) rectal reservoir function. Control values were obtained from two groups of 11 (seven F, 32-53 yr), and 32 (18 F, 19-44 yr) volunteers. RESULTS: Patients had urge (14), passive (four), or combined (four) fecal incontinence; symptoms were mild in three, moderate in nine, and severe in 10 patients. Most had low sphincteric pressures and ultrasonic abnormalities. Temperature perception was impaired (p < 0.05) in incontinent patients, to a greater extent in the proximal anal canal and in patients with passive, as opposed to urge, incontinence. Intraluminal pressures for sensations of rectal distension were lower in incontinent patients (p = 0.02). Artificial stools elicited sensations of rectal filling at lower volumes than did a barostat bag, and in patients with urge, as opposed to passive, incontinence. In patients and controls, the sensation of urgency was associated (r2 = 0.2, p < 0.01) with rectal compliance. CONCLUSIONS: We confirm that temperature sensation is impaired, and perception of rectal distension is not always reduced in fecal incontinence. Artificial stool tended to induce sensations at lower volumes than did balloon inflation. Altered sensory mechanisms may contribute to the pathophysiology of fecal incontinence.     

Preoperative Anal Manometry Predicts Continence After Perineal Proctectomy for Rectal Prolapse

Purpose This study examines whether preoperative anal manometry and pudendal nerve terminal motor latency predict functional outcome after perineal proctectomy for rectal prolapse. Methods All adult patients treated by perineal proctectomy for rectal prolapse from 1995 to 2004 were identified (N = 106). Forty-five patients underwent anal manometry and pudendal nerve terminal motor latency testing before proctectomy and they form the basis for this study. Results Perineal proctectomy with levatoroplasty (anterior 88.9 percent; posterior 75.6 percent) was performed in all patients, with a mean resection length of 10.4 cm. Four patients (8.9 percent) developed recurrent prolapse during a 44-month mean follow-up. Preoperative resting and maximal squeeze pressures were 34.2 ± 18.3 and 60.4 ± 30.5 mmHg, respectively. Pudendal nerve terminal motor latency testing was prolonged or undetectable in 55.6 percent of patients. Grade 2 or 3 fecal incontinence was reported by 77.8 percent of patients before surgery, and one-third had obstructed defecation. The overall prevalence of incontinence (77.8 vs. 35.6 percent, P < 0.0001) and constipation (33.3 vs. 6.7 percent, P = 0.003) decreased significantly after proctectomy. Patients with preoperative squeeze pressures >60 mmHg (n = 19) had improved postoperative fecal continence relative to those with lower pressures (incontinence rate, 10 vs. 54 percent; P = 0.004), despite having similar degrees of preoperative incontinence. Abnormalities of pudendal nerve function and mean resting pressures were not predictive of postoperative incontinence. Conclusions Perineal proctectomy provides relief from rectal prolapse, with good intermediate term results. Preoperative anal manometry can predict fecal continence rates after proctectomy, because patients with maximal squeeze pressures >60 mmHg have significantly improved outcomes. Supported exclusively using institutional funding. Presented at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, April 30 to May 5, 2005.     

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 Manometry: A Comparison of Techniques

Purpose Methods of anal manometry vary between centers, resulting in potential difficulties in interpretation of results. This study compared several accepted manometric techniques in healthy control subjects and in patients with fecal incontinence. Methods Eleven patients with fecal incontinence (M:F = 3:8; mean age = 67 years) and ten healthy control subjects (M:F = 3:7; mean age = 64 years) underwent anal manometry using five different methods: 1) water-perfused side hole; 2) water-perfused end hole; 3) microtransducer; 4) microballoon; 5) portable Peritron. Using a station pull-through technique, anal pressures (resting, squeeze, and cough pressures) were recorded at 1-cm intervals from rectum to anal verge, as well as radial pressures in four quadrants for Methods 1 and 2. Results Water perfusion side hole recorded slightly higher maximal resting pressures; however, there were no significant differences between any of the methods. In healthy control subjects, distal maximal squeeze pressures were significantly higher (P < 0.05) than proximally as measured by microtransducer. There were slight (nonsignificant) variations in radial pressures with water perfusion and microtransducer. Peritron values for maximum resting pressure and maximum squeeze pressure were lower than those recorded by water perfusion side hole by a factor of 0.8. Conclusions There is no significant variation in anal pressure recordings using standard manometry techniques. Variations in radial pressures are slight and not significant in clinical studies. Results obtained with portable nonperfusion systems must be interpreted appropriately. Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, June 24 to 29, 2000.     

Anal inspection and digital rectal examination compared to anorectal physiology tests and endoanal ultrasonography in evaluating fecal incontinence

Background Anal inspection and digital rectal examination are routinely performed in fecal incontinent patients but it is not clear to what extent they contribute to the diagnostic work-up. We examined if and how findings of anal inspection and rectal examination are associated with anorectal function tests and endoanal ultrasonography. Methods A cohort of fecal incontinent patients (n=312, 90% females; mean age 59) prospectively underwent anal inspection and rectal examination. Findings were compared with results of anorectal function tests and endoanal ultrasonography. Results Absent, decreased and normal resting and squeeze pressures at rectal examination correlated to some extent with mean (±SD) manometric findings: mean resting pressure 41.3 (±20), 43.8 (±20) and 61.6 (±23) Hg (p<0.001); incremental squeeze pressure 20.6 (±20), 38.4 (±31) and 62.4 (±34) Hg (p<0.001). External anal sphincter defects at rectal examination were confirmed with endoanal ultrasonography for defects <90 degrees in 36% (37/103); for defects between 90-150 degrees in 61% (20/33); for defects between 150-270 degrees in 100% (6/6). Patients with anal scar tissue at anal inspection had lower incremental squeeze pressures (p=0.04); patients with a gaping anus had lower resting pressures (p=0.013) at anorectal manometry. All other findings were not related to any anorectal function test or endoanal ultrasonography. Conclusions Anal inspection and digital rectal examination can give accurate information about internal and external anal sphincter function but are inaccurate for determining external anal sphincter defects <90 degrees. Therefore, a sufficient diagnostic work-up should comprise at least rectal examination, anal inspection and endoanal ultrasonography.     

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     

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.     

Fecal incontinence with normal anal canal pressures: where is the pitfall?

OBJECTIVE: One third of subjects who suffer from fecal incontinence are found to have values within the normal range when anal manometry is performed. For these patients, one hypothesis is that impaired rectal adaptation to distension may occur. The aim of our study was to analyze anorectal responses to rectal isobaric distension in this population. METHODS: This was a prospective study conducted in 51 consecutive incontinent patients (45 female, six male) divided into two groups according to their functional anal state: absence (19 patients aged 55 +/- 6 yr) or presence of manometric anal weakness (32 patients aged 59 +/- 2 yr). The subjects were submitted to two randomized modes of rectal isobaric distension (tonic, phasic) with an electronic barostat. Anal pressures, perception, and volumes of the rectum were recorded at six different preselected pressures. RESULTS: As compared with those having anal weakness, patients with no anal weakness retained higher mean pressures at both upper (36.9 +/- 2.2 vs 22.9 +/- 1.4 mm Hg; p = 0.01) and lower parts (41.0 +/- 2.0 vs 23.3 +/- 1.4 mm Hg; p = 0.002) of the anal canal, similar perception scores, but much lower rectal volumes (68.5 +/- 5.5 vs 121.8 +/- 7.0 ml; p = 0.008) in response to rectal isobaric distension. CONCLUSION: A decrease in rectal adaptation could be involved in fecal leakage in patients with no anal manometric weakness.     

Anorectal function investigations in incontinent and continent patients

Anal manometry, rectal capacity measurement, and the saline-infusion test were performed in 350 patients, 178 of whom had fecal incontinence and 172 of whom were continent. Anal manometry was also performed in 80 control subjects, whose results were compared with the patients. Women and older patients exhibited lower pressures. Compared with continent patients, incontinent patients had lower anal sphincter pressures at rest and during squeeze, a smaller rectal capacity, and leaked earlier and more with the saline infusion test. Differentiation between incontinent and continent patients was not possible with a single test because there was complete overlap. The maximum squeeze pressure showed the best discrimination. Combining the three tests did not show better discrimination than any individual test. Anal pressure and rectal capacity below the normal range only were found in very few incontinent patients. The authors' study demonstrates that no prediction can be made about continence with anorectal function tests. Therefore, in the individual patient, an abnormal result in one test must be interpreted with caution and only in relationship with other tests, especially when therapeutic surgery is considered.