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Iatrogenic faecal incontinence can be split into two broad categories by aetiology. The largest group comprises patients undergoing proctological surgery for haemorrhoids, fissures, sepsis, rectoceles and local excision of rectal neoplasia. A second surgical group includes patients who have received anal instrumentation for the purpose of performing an anastomosis in the pelvis, most commonly by transanal insertion of a stapling device. [ABSTRACT FROM AUTHOR]

The frequency of fecal incontinence (FI) in patients submitted to rectal resection (RR) for cancer ranges between 2% and 40% [1-6]. In fact, despite the significant improvements registered over the last few decades in the treatment of rectal cancer, not only in the control of the neoplasm itself and sparing of the anal sphincters but also in the preservation of urinary and sexual function [6-19], FI can occur, with severe detrimental effects on patients' quality of life. In these patients, FI is a disabling clinical condition, the etiology of which is complex and not yet fully elucidated. It is regarded as a component of "anterior resection syndrome," including an increased number of daily bowel movements, clustering, FI, and soiling after this operation [20-22]. In some cases, urinary incontinence also contributes to worsening of the clinical condition. Even if these patients are comforted by the fact that they have won their fight against the cancer, their personal and social life suffers considerably. Unfortunately, the minimalist attitude of some physicians prevents these patients from exploring the possibilities of treatment other than an appropriate diet or stimulating systems to empty the bowel completely. [ABSTRACT FROM AUTHOR]

As a common denominator of all the clinical aspects treated in this book, there is the awareness of potential benefits derived from rational management of fecal incontinence (FI) and the need for further efforts to improve the effectiveness of traditional and new treatments. Indeed, although progress made in this field during the last few decades has been significant, the lack of detailed knowledge in the physiology of fecal continence far too frequently makes the application of therapeutic procedures empiric and pragmatic. Moreover, there are discrepancies between countries and regions in referring patients to centers dedicated to FI management. This causes different attitudes in performing a homogeneous diagnostic workup, in application of similar strict selection criteria to the variety of available treatments, and in reporting results of the applied therapies. Worldwide, national institutes for health inadequately support medical research on FI treatment, even though the social, economic, and clinical importance of FI to society has been very well recognized. On the other hand, research into FI is all too frequently sponsored only by companies with a commercial interest in the subject. [ABSTRACT FROM AUTHOR]

Fecal incontinence represents a devastating problem for all those who suffer from it. It often prevents a person from becoming socially accepted, which in turn provokes serious psychological sequelae. It is a problem that impacts more children than previously thought, affecting those born with anorectal malformations and Hirschsprung's disease as well as children with spinal cord problems or spinal injuries. [ABSTRACT FROM AUTHOR]

Double incontinence (DI) is the concomitant presence of urinary and anal incontinence in the same subject. This condition is widely underreported due to social stigma and embarrassment. In fact, women who suffer from both diseases have greater impairment regarding their physical and psychosocial wellbeing than do women suffering from isolated urinary incontinence (UI) or fecal incontinence (FI) [1], resulting in social isolation and reduced quality of life [2]. Few studies have evaluated the prevalence of DI. The different results of these studies depend on the method utilized for data collection and on the demographic features of the study population. Table 1 shows the prevalence of DI reported by various authors [3-9]. [ABSTRACT FROM AUTHOR]

Radiation injury is a well-known complication after external radiotherapy of cancers within the pelvic cavity. Radiation therapy might be the primary treatment for such cancers (prostate, uterine, cervical, bladder, and anal cancers), or it might be combined with surgery (rectal cancer). [ABSTRACT FROM AUTHOR]

At any age, fecal incontinence is one of the most devastating of all nonfatal illnesses, resulting in considerable embarrassment, anxiety, and social isolation to those who suffer from it. So embarrassing is it that individuals with incontinence frequently do not volunteer this complaint to their physicians and must be asked directly about fecal incontinence [1]. The physician should also be aware that patients might complain of "diarrhea," which may be a euphemism for fecal incontinence. [ABSTRACT FROM AUTHOR]

It is now recognised, albeit relatively recently, that chronic gastrointestinal symptoms represent a clinically important problem in a substantial number of people who have type 1 or type 2 diabetes [1, 2]. Whereas the amount of information relating to anorectal function in diabetes is limited, it is clear that faecal incontinence occurs relatively frequently [1, 3, 4] and is often overlooked as a cause of morbidity. [ABSTRACT FROM AUTHOR]

Fecal incontinence, according to the most used definition, is the "involuntary loss of the stool or soiling at a socially inappropriate time or place" [1]. It is an important health issue that strongly affects patient quality of life and restricts their social activities. It is a common problem, with prevalence ranging from 2.2% to 15% in the community and up to 40% in nursing homes [2]. The prevalence of fecal incontinence in neurological patients is higher than in the general population. Many neurological disorders are associated with fecal incontinence, and this chapter is a review of the current clinical knowledge regarding the pathogenesis and clinical findings. When considering the possible effects of central and peripheral neurological lesions on fecal continence, it is important to keep in mind that continence depends on intact neural pathways and normal function of the cerebral, spinal, and cauda equina centers, and peripheral nerves. It should be remembered, however, that signs, symptoms, and gastrointestinal dysfunction may differ from expectations by virtue of incomplete neuronal lesions, coexisting involvement of supraspinal or spinal centers, or damage to the distal parts of the autonomic or somatic innervation of the pelvic floor sphincter muscles. [ABSTRACT FROM AUTHOR]

Data from the obstetrical literature show that about 0.4-3.7% of all vaginal deliveries result in a thirdor fourth-degree perineal laceration [1, 2]. Rarely, the reported incidence can go as high as 20-39% [3, 4]. When a third- or fourth-degree perineal laceration occurs during vaginal delivery, the standard repair is to approximate the torn ends of the anal sphincter using two to six interrupted mattress or figure-of-eight stitches and close the vaginal and perineal tissues in layers. Postpartum, the patient is typically put on a soft diet and given a stool softener for 7-10 days. This method of repair is described in the latest edition of Williams Obstetrics [5], the newest edition of [6], and numerous other obstetrical textbooks. [ABSTRACT FROM AUTHOR]

During the nineteenth century, at the current location of the famous Waldorf-Astoria Hotel in New York City, stood the first hospital in the world dedicated to the care of women with obstetric fistulas and complications [1]. By the end of that century, advances in obstetrics had dramatically decreased the severe complications of labor and delivery, and the hospital was closed. Currently, hospitals dedicated to the treatment of obstetric injury, particularly obstetric fistulas, exist in areas of the world that continue to struggle with the devastating effects of prolonged childbirth, obstructed labor, and maternal mortality [2]. [ABSTRACT FROM AUTHOR]

The term "sphincter atrophy" refers mostly to external anal sphincter (EAS) atrophy, as the EAS is the most important factor for maintaining fecal continence. EAS atrophy, often due to pudendal neuropathy caused by stretch injury during childbirth [1] or chronic constipation [2, 3], is an important cause of fecal incontinence. When a woman is fecally incontinent and there is a history of a difficult childbirth with prolonged labor or chronic constipation as well as a sphincter rupture, there is always a chance that, besides the rupture, some atrophy is present in the EAS. [ABSTRACT FROM AUTHOR]

The term rectal prolapse can be associated with three different clinical entities: full-thickness rectal prolapse, mucosal prolapse and internal rectal intussusception. Full-thickness rectal prolapse is the most commonly recognised type and is defined as protrusion of the full thickness of the rectal wall through the anus. In mucosal prolapse, only the rectal mucosa protrudes from the anus. Internal intussusception may be a full thickness or a partial rectal-wall disorder, but the prolapsed tissue does not pass beyond the anal canal and does not pass out of the anus. This chapter focuses on full-thickness rectal prolapse with specific regard to associated faecal incontinence. [ABSTRACT FROM AUTHOR]

Fecal incontinence is a multifactorial disease. Anorectal physiology studies play an outstanding role in the evaluation of its etiology and severity, the two main factors that constitute the basis for the correct choice of treatment. However, the prognostic role of clinical factors and anorectal physiological tests in predicting the outcome to either conservative or surgical treatment is questionable. [ABSTRACT FROM AUTHOR]

Faecal incontinence is a common but complex problem that can be difficult to treat successfully. Whereas some patients are helped by antidiarrhoeal drugs such as loperamide or codeine phosphate, this is a holding measure rather than a cure. Surgical treatments are limited, and some are complex with a high morbidity rate. The search for minimally invasive therapies continues. Sacral nerve stimulation is becoming the preferred option in many cases of internal and external anal sphincter dysfunction, but it is expensive and involves a two-stage procedure. [ABSTRACT FROM AUTHOR]

Fecal incontinence is a socially disabling problem that is underestimated but widespread. Approximately 2% of the general population suffer from the inability to control bowel emptying [1], and this rate rises with age: up to 11% of men and 26% of women over age 50 [2]. Its impact on society is substantial. Only a small portion of this population has to be treated surgically. [ABSTRACT FROM AUTHOR]

Fecal incontinence is a devastating condition in which patients have extremely poor quality of life, with limitations in social interaction, physical activity, and employability. Defined as incomplete control of the fecal stream, fecal incontinence may be due to a number of factors, such as increased stool production, decreased rectal vault capacitance, diminished rectal distension sensibility, and anal sphincter disruption. Despite such medical therapies as motility inhibitors, stool-bulking agents, biofeedback, and Kegel exercises, these interventions may only provide limited relief from this disabling condition [1]. [ABSTRACT FROM AUTHOR]

Fecal incontinence is a severe disability that deeply affects the quality of life of the afflicted patient. The estimated prevalence in the general population ranges from 1% to 17%. In France, it is estimated that 350,000 persons over the age of 45 years have a severe form of fecal incontinence. In the event of ineffective medical treatment and the inability or failure of conventional surgery, the only choice for these patients until recently was to accept their condition or opt for end colostomy. However, technological progress has opened up the prospect of effective therapy for severe fecal incontinence both in terms of performance and long-term reliability. Replacement of sphincter function by an artificial bowel sphincter is one available option that has shown promising results. [ABSTRACT FROM AUTHOR]

Fecal incontinence is a terrible burden for patients. In severe forms of incontinence, patients feel excluded from any social interaction. They prefer to stay at home close to the toilet and try to avoid shopping, attending parties, or visiting friends. If they do go into public places, they know the location of every public toilet. Even in their own homes, most of them have rules with partner and children that the moment the patient feels any urge, the toilet must be free immediately. People who are not familiar with this phenomenon can hardly understand how terrible this can be for patients. Fecal continence is so normal and taken for granted that those who have never experienced it cannot imagine how life would be if the moment arrived when he or she became incontinent. The world shrinks to a size no bigger than the patient's home. These patients have the choice of either accepting such a life or accepting a colostomy. [ABSTRACT FROM AUTHOR]

Postanal repair was developed by Sir Allan Parks in the 1970s [1] and popularised in the early 1980s for patients with neuromyopathic faecal incontinence. The original objective of this operation was to restore the anorectal angle, which was thought to be an important factor in continence. In 1975, Parks suggested the flap-valve theory that stressed the importance of the acute anorectal angle. According to this theory, a rise in intra-abdominal pressure caused the upper end of the anal canal to be occluded by anterior rectal mucosa, preventing rectal contents from entering the anal canal. Neuromyopathic faecal incontinence was associated with perineal descent and an obtuse anorectal angle, which rendered the flap-valve-like mechanism ineffective. Further investigations, however, failed to show changes of the anorectal angle, and currently, it is thought that an improvement of muscular contractility is responsible for any improvement in continence [2]. [ABSTRACT FROM AUTHOR]

Fecal incontinence, as a result of trauma to the muscular sphincter complex, has long been surgically treated by approximation of healthy muscular edges on either side of the defect. In his 1923 textbook, Lockhart-Mummery described the operative procedure of mobilizing muscle lateral to the defect and sewing the "ends firmly in contact" [1]. Operative success was "usually most satisfactory," yet contingent on "proper antiseptic precautions" and "carefully performed" technique. In 1940, however, Blaisdell reported general dissatisfaction among American proctologists with this classic "plastic repair" due to infectious complications, technical challenges, and poor outcomes [2]. Blaisdell went on to describe two techniques that involved overlapping muscle edges while leaving the scarred portion of the sphincter intact. The "reefing operation" brought together muscle opposite the site of damage to narrow the circumference of the anal outlet and thus avoid manipulation of the damaged portion of the sphincter [2]. [ABSTRACT FROM AUTHOR]

Fecal continence depends on the interaction of many factors. Anal sphincters, pelvic floor muscles, anal sensation, rectal sensory-motor activity, and neural integrity all have determinant roles, which together provide a coordinated mechanism of gas and stool continence. The pathophysiology of fecal incontinence is, therefore, often multifactorial, and each patient has his or her own specific pathogenetic profile as a result of a mix of etiological factors. It is clear that any treatment for fecal incontinence must allow for this fundamental aspect, and each patient thus requires a clinical approach that has been modulated on his or her specific incontinence etiology. This basic fact must be considered when planning therapy for a patient with fecal incontinence. [ABSTRACT FROM AUTHOR]

Criteria for patient selection to a certain treatment are of central importance in the management of fecal incontinence (FI). Even though the understanding of continence physiology has improved, there persists a lack of comprehensive knowledge regarding the very complex mechanisms by which various structures contribute to the regulation of continence control. It is now assumed that a continuous modulation of different stimuli is necessary to effectively maintain the various functions involved with continence. On the other hand, the instruments available to measure or analyze parameters associated with continence, albeit numerous and sometimes sophisticated, are not used in a standardized manner, so that data obtained at one center are not comparable with those obtained in another. Also, the entire diagnostic workup is still debatable, being routinely limited to clinical examination in the opinion of some, whereas others recommend extensive evaluation. However, other aspects must be considered in the decision-making process surrounding treatment choice. [ABSTRACT FROM AUTHOR]

Anal continence is assured by the activity of complex anatomical and physiological structures (anal sphincters, pelvic floor musculature, rectal curvatures, transverse rectal folds, rectal reservoir, rectal sensation). It is dependent also on numerous other factors, such as stool consistency, patient's mental faculties and mobility, and social convenience. Only if there is an effective, coordinated integration between these elements can defecation proceed normally. On the other hand, fecal incontinence (FI) is the result of disruption of one or several of these different entities: frequently, it can be due to a multifactorial pathogenesis, and in many cases, it is not secondary to sphincter tears. The disruption could lie in alterations intrinsic to the anorectal neuromuscular structures of continence control or be extrinsic to them, involving extrapelvic control mechanisms. The primary aim of an effective therapeutic approach must be the improvement-better, the resolution-of this distressing condition. Different forms of therapy are now available so that physicians must select the best option for each patient. [ABSTRACT FROM AUTHOR]

Fecal incontinence, the inability to deliberately control the anal sphincter, is a common disease and may affect up to 20% of the age group above 65 years [1]. Fecal incontinence has a substantial impact on quality of life. It is a socially disabling problem that prevents up to one third of patients from seeking medical advice for it. The most common causes include traumatic (obstetric, surgical) sphincter defects, neurogenic dysfunction of the musculature of the pelvic floor, and rectal prolapse. The prevalence of fecal incontinence in women is eight times higher than in men [2]. The most common cause in women is child-birth, during which the sphincter muscles are commonly damaged [3 4 5]. Traumatic rupture of the anal sphincters may result in immediate-onset fecal incontinence. Pudendal neuropathy, caused by stretching the branches of the pudendal nerve to the sphincter and levator ani as the fetal head pushes down on the pelvic floor to dilate the introitus, leads to delayed-onset incontinence. Following vaginal delivery, the pudendal nerve terminal motor latencies (PNTML) are increased for about 6 months, and there is a fall in squeeze pressure regardless of sphincter damage [6]. [ABSTRACT FROM AUTHOR]

Endoanal ultrasound (EUS) was introduced 20 years ago by urologists to evaluate the prostate. Later, EUS was extended to other specialists-; first to stage rectal tumors, and next to investigate benign disorders of the anal sphincters and pelvic floor. [ABSTRACT FROM AUTHOR]

Fecal incontinence is a consequence of functional disturbances in the mechanisms that regulate continence and defecation. In this chapter, we review the functional anatomy and physiology of the anorectum, pathogenic mechanisms, and diagnostic approaches for fecal incontinence. [ABSTRACT FROM AUTHOR]

Besides physiologic investigations and radiology imaging, diagnosis of fecal incontinence requires accurate clinical assessment. By means of a structured scheme, clinical assessment aims to evaluate the whole picture: whether the patient is really incontinent, the etiology of the incontinence, and the nature and severity of the problem. Nevertheless, we must keep in mind that when treating an individual patient, these data may not be enough to define the pathophysiology of the symptom and, therefore, we need the investigations we mentioned initially. [ABSTRACT FROM AUTHOR]

Health care expenditure in the most economically advanced countries seems to have spiraled out of control over the last few decades. There are three main reasons accounting for this situation: ageing of the population has led to an increase in the numbers requiring health care services, the accelerating pace of technological development has given rise to new techniques that have improved the quality of treatment, and with the introduction of new, increasingly costly, products, patient expectations have changed and patients thus demand better medical treatment. The combination of these three factors has resulted in health care spending becoming increasingly difficult to control. [ABSTRACT FROM AUTHOR]

Given the psychological, social, and functional impacts that fecal incontinence (FI) has on an individual, the assessment of health-related quality of life (HRQoL) is an important consideration when evaluating the efficacy of treatment. An individual with FI faces a serious set of challenges in living life, and as a result, providers are also faced with consideration of these issues in providing treatment. For example, the implantation of an artificial sphincter is about more than technical procedures; it is also about its impact on the individual's ability to live life. [ABSTRACT FROM AUTHOR]

There are many routes to becoming a patient with faecal incontinence (FI), many aetiologies of the disorder, and many personal histories. The "meaning" of the FI will be different for each patient, and his or her way of managing it will depend not only on aetiology but also on a number of personal, social and medical factors. Is the FI secondary to a medical or surgical mishap, or is it the by product of a life-saving surgical resection, an "act of God", or an "act of man"? Has the FI been with the patient since childhood, and has he or she developed coping strategies; or is it of recent onset and as yet "new", foreign and unmanageable? What medical support is available to the patient? What emotional support-from family, partner, friends and work associates-is available? Is the partner supportive, or resentful and disgusted? What habitual defence mechanisms do, the patient use in order to deal with adversity, and are these mechanisms overall successful or counterproductive? [ABSTRACT FROM AUTHOR]

Continence is a highly complex physiological function requiring coordinated activity of brain and central nervous system (CNS), autonomic and enteric nervous systems; a gastrointestinal tract of adequate length and biomechanical properties; and a competent anal sphincter complex, many components of which remain incompletely understood. In a minority of cases, for example incontinence immediately following fistulotomy for a high anal fistula in an otherwise "normal" individual, the cause-effect relationship is clear. For the majority, however, temporal relationships are not so evident, e.g. onset of symptoms several decades following a clinically uneventful vaginal delivery but one in which covert sphincter damage occurred, in which association between event and symptoms is less clear, and in which the event may be just one component of a multifactorial aetiology. Structural sphincteric causes of incontinence are relatively easy to investigate; at the most simplistic level, faecal continence depends upon anal pressure being higher than rectal pressure, and that this situation may be maintained predominantly by internal anal sphincter function, augmented at times of increased rectal pressure by voluntary anal muscle contraction, reflex or conscious, and orchestrated by intact sensation. [ABSTRACT FROM AUTHOR]