ABSTRACT
Anal incontinence is a symptom represented by the impaired ability to control the elimination of gas and stool, with an estimated incidence of 2.2 to 7.1% of the population. These numbers likely under-represent the true prevalence because physicians and patients are reluctant to discuss this problem. Evaluation of the patient with anal incontinence requires a fundamental knowledge of the etiologic factors. Careful history and physical examination is essential in every patient and can identify the cause of most cases of incontinence. Incontinence scoring systems are tools that provide objective data regarding the severity and quality of anal incontinence. Supplemental special tests for evaluating incontinence should be aimed at achieving three goals: (1) provide additional and confirmatory information regarding the diagnosis and cause of incontinence; (2) select appropriate treatment; and (3) predict treatment outcome. Numerous studies to evaluate anal incontinence exist; however, the most useful tests to achieve these goals are anal manometry, pudendal nerve terminal motor latency, and anal endosonography, because these studies can identify physiologic, neurologic, and anatomic abnormalities of the anorectum for which there may be effective treatments.
KEYWORDS
Anal - fecal - incontinence - evaluation
REFERENCES
-
1
Johanson J F, Lafferty J.
Epidemiology of fecal incontinence: the silent affliction.
Am J Gastroenterol.
1996;
91
33-36
-
2
Enck P, Bielefeldt K, Rathmann W, Purrmann J, Tschope D, Erckenbrecht J F.
Epidemiology of faecal incontinence in selected patient groups.
Int J Colorectal Dis.
1991;
6
143-146
-
3
Nelson R, Norton N, Cautley E, Furner S.
Community-based prevalence of anal incontinence.
JAMA.
1995;
274
559-561
-
4
Drossman D A, Li Z, Andruzzi E et al..
U.S. householder survey of functional gastrointestinal disorders. Prevalence, sociodemography, and health impact.
Dig Dis Sci.
1993;
38
1569-1580
-
5
Nelson R, Furner S, Jesudason V.
Fecal incontinence in Wisconsin nursing homes: prevalence and associations.
Dis Colon Rectum.
1998;
41
1226-1229
-
6
Jorge J M, Wexner S D.
Etiology and management of fecal incontinence.
Dis Colon Rectum.
1993;
36
77-97
-
7
Lunniss P J, Gladman M A, Hetzer F H, Williams N S, Scott S M.
Risk factors in acquired faecal incontinence.
J R Soc Med.
2004;
97
111-116
-
8
Thacker S B, Banta H D.
Benefits and risks of episiotomy: an interpretative review of the English language literature, 1860-1980.
Obstet Gynecol Surv.
1983;
38
322-338
-
9
Donnelly V, Fynes M, Campbell D, Johnson H, O'Connell P R, O'Herlihy C.
Obstetric events leading to anal sphincter damage.
Obstet Gynecol.
1998;
92
955-961
-
10
Sultan A H, Kamm M A, Hudson C N, Thomas J M, Bartram C I.
Anal-sphincter disruption during vaginal delivery.
N Engl J Med.
1993;
329
1905-1911
-
11
Mavrantonis C, Wexner S D.
A clinical approach to fecal incontinence.
J Clin Gastroenterol.
1998;
27
108-121
-
12
Tobin G W, Brocklehurst J C.
Faecal incontinence in residential homes for the elderly: prevalence, aetiology and management.
Age Ageing.
1986;
15
41-46
-
13
Gurll N, Steer M.
Diagnostic and therapeutic considerations for fecal impaction.
Dis Colon Rectum.
1975;
18
507-511
-
14
Iwamoto T, Nakahara S, Mibu R, Hotokezaka M, Nakano H, Tanaka M.
Effect of radiotherapy on anorectal function in patients with cervical cancer.
Dis Colon Rectum.
1997;
40
693-697
-
15
Trezza M, Krogh K, Egekvist H, Bjerring P, Laurberg S.
Bowel problems in patients with systemic sclerosis.
Scand J Gastroenterol.
1999;
34
409-413
-
16
Leighton J A, Valdovinos M A, Pemberton J H, Rath D M, Camilleri M.
Anorectal dysfunction and rectal prolapse in progressive systemic sclerosis.
Dis Colon Rectum.
1993;
36
182-185
-
17
Felt-Bersma R J, Janssen J J, Klinkenberg-Knol E C, Hoitsma H F, Meuwissen S G.
Soiling: anorectal function and results of treatment.
Int J Colorectal Dis.
1989;
4
37-40
-
18
Rao S S, Sun W M.
Current techniques of assessing defecation dynamics.
Dig Dis.
1997;
15
64-77
-
19
Keating J P, Stewart P J, Eyers A A, Warner D, Bokey E L.
Are special investigations of value in the management of patients with fecal incontinence?.
Dis Colon Rectum.
1997;
40
896-901
-
20
Coller J A.
Clinical application of anorectal manometry.
Gastroenterol Clin North Am.
1987;
16
17-33
-
21
Chen H, Humphreys M S, Kettlewell M G, Bulkley G B, George B D.
Anal ultrasound predicts the response to nonoperative treatment of fecal incontinence in men.
Ann Surg.
1999;
229
739-743
-
22
Ternent C A, Shashidharan M, Blatchford G J, Christensen M A, Thorson A G, Sentovich S M.
Transanal ultrasound and anorectal physiology findings affecting continence after sphincteroplasty.
Dis Colon Rectum.
1997;
40
462-467
-
23
Sangwan Y P, Coller J A, Barrett R C et al..
Unilateral pudendal neuropathy. Impact on outcome of anal sphincter repair.
Dis Colon Rectum.
1996;
39
686-689
-
24
Chen A S, Luchtefeld M A, Senagore A J, Mackeigan J M, Hoyt C.
Pudendal nerve latency. Does it predict outcome of anal sphincter repair?.
Dis Colon Rectum.
1998;
41
1005-1009
-
25
Sun W M, Rao S S.
Manometric assessment of anorectal function.
Gastroenterol Clin North Am.
2001;
30
15-32
-
26
Parks T G.
The usefulness of tests in anorectal disease.
World J Surg.
1992;
16
804-810
-
27
Schweiger M.
Method for determining individual contributions of voluntary and involuntary anal sphincters to resting tone.
Dis Colon Rectum.
1979;
22
415-416
-
28
Duthie H L, Watts J M.
Contribution of the external anal sphincter to the pressure zone in the anal canal.
Gut.
1965;
28
64-68
-
29
Lubowski D Z, Nicholls R J, Swash M, Jordan M J.
Neural control of internal anal sphincter function.
Br J Surg.
1987;
74
668-670
-
30
Jorge J M, Wexner S D.
Anorectal manometry: techniques and clinical applications.
South Med J.
1993;
86
924-931
-
31
Karulf R E, Madoff R D, Goldberg S M.
Rectal prolapse.
Curr Probl Surg.
2001;
38
771-832
-
32
Fernandez-Fraga X, Azpiroz F, Aparici A, Casaus M, Malagelada J R.
Predictors of response to biofeedback treatment in anal incontinence.
Dis Colon Rectum.
2003;
46
1218-1225
-
33
Wexner S D, Marchetti F, Salanga V D, Corredor C, Jagelman D G.
Neurophysiologic assessment of the anal sphincters.
Dis Colon Rectum.
1991;
34
606-612
-
34
Hill J, Hosker G, Kiff E S.
Pudendal nerve terminal motor latency measurements: what they do and do not tell us.
Br J Surg.
2002;
89
1268-1269
-
35
Madoff R D.
Surgical treatment options for fecal incontinence.
Gastroenterology.
2004;
126
S48-S54
-
36
Wexner S D, Marchetti F, Jagelman D G.
The role of sphincteroplasty for fecal incontinence reevaluated: a prospective physiologic and functional review.
Dis Colon Rectum.
1991;
34
22-30
-
37
Londono-Schimmer E E, Garcia-Duperly R, Nicholls R J, Ritchie J K, Hawley P R, Thomson J P.
Overlapping anal sphincter repair for faecal incontinence due to sphincter trauma: five year follow-up functional results.
Int J Colorectal Dis.
1994;
9
110-113
-
38
Simmang C, Birnbaum E H, Kodner I J, Fry R D, Fleshman J W.
Anal sphincter reconstruction in the elderly: does advancing age affect outcome?.
Dis Colon Rectum.
1994;
37
1065-1069
-
39
Nikiteas N, Korsgen S, Kumar D, Keighley M R.
Audit of sphincter repair. Factors associated with poor outcome.
Dis Colon Rectum.
1996;
39
1164-1170
-
40
Gilliland R, Altomare D F, Moreira Jr H, Oliveira L, Gilliland J E, Wexner S D.
Pudendal neuropathy is predictive of failure following anterior overlapping sphincteroplasty.
Dis Colon Rectum.
1998;
41
1516-1522
-
41
Buie W D, Lowry A C, Rothenberger D A, Madoff R D.
Clinical rather than laboratory assessment predicts continence after anterior sphincteroplasty.
Dis Colon Rectum.
2001;
44
1255-1260
-
42
Enck P, von Giesen H J, Schafer A et al..
Comparison of anal sonography with conventional needle electromyography in the evaluation of anal sphincter defects.
Am J Gastroenterol.
1996;
91
2539-2543
-
43
Sentovich S M, Wong W D, Blatchford G J.
Accuracy and reliability of transanal ultrasound for anterior anal sphincter injury.
Dis Colon Rectum.
1998;
41
1000-1004
-
44
Sultan A H, Kamm M A, Talbot I C, Nicholls R J, Bartram C I.
Anal endosonography for identifying external sphincter defects confirmed histologically.
Br J Surg.
1994;
81
463-465
-
45
Saclarides T J.
Endorectal ultrasound.
Surg Clin North Am.
1998;
78
237-249
-
46
Felt-Bersma R J, Cuesta M A, Koorevaar M.
Anal sphincter repair improves anorectal function and endosonographic image. A prospective clinical study.
Dis Colon Rectum.
1996;
39
878-885
-
47
deSouza N M, Hall A S, Puni R, Gilderdale D J, Young I R, Kmiot W A.
High resolution magnetic resonance imaging of the anal sphincter using a dedicated endoanal coil. Comparison of magnetic resonance imaging with surgical findings.
Dis Colon Rectum.
1996;
39
926-934
-
48
Rociu E, Stoker J, Zwamborn A W, Lameris J S.
Endoanal MR imaging of the anal sphincter in fecal incontinence.
Radiographics.
1999;
19
S171-S177
-
49
Rociu E, Stoker J, Eijkemans M J, Schouten W R, Lameris J S.
Fecal incontinence: endoanal US versus endoanal MR imaging.
Radiology.
1999;
212
453-458
-
50
Briel J W, Stoker J, Rociu E, Lameris J S, Hop W C, Schouten W R.
External anal sphincter atrophy on endoanal magnetic resonance imaging adversely affects continence after sphincteroplasty.
Br J Surg.
1999;
86
1322-1327
-
51
Briel J W, Zimmerman D D, Stoker J et al..
Relationship between sphincter morphology on endoanal MRI and histopathological aspects of the external anal sphincter.
Int J Colorectal Dis.
2000;
15
87-90
-
52
Malouf A J, Williams A B, Halligan S, Bartram C I, Dhillon S, Kamm M A.
Prospective assessment of accuracy of endoanal MR imaging and endosonography in patients with fecal incontinence.
AJR Am J Roentgenol.
2000;
175
741-745
-
53
Williams A B, Malouf A J, Bartram C I, Halligan S, Kamm M A, Kmiot W A.
Assessment of external anal sphincter morphology in idiopathic fecal incontinence with endocoil magnetic resonance imaging.
Dig Dis Sci.
2001;
46
1466-1471
Harry T PapaconstantinouM.D.
Department of Surgery, The University of Texas Southwestern Medical Center
5323 Harry Hines Blvd., Dallas, TX 75390-9156
Email: harry.papaconstantinou@utsouthwestern.edu
