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Late sequelae to cancer treatment of the pelvic organs are common. Gastrointestinal symptoms including chronic diarrhoea, faecal urgency, and faecal incontinence are some of the most disabling with a negative impact on quality of life. By investigating and treating the gastrointestinal symptoms in specialised late adverse effects clinics more than half of the patients can be helped. The treatment is individually tailored depending on the patients' main symptoms and underlying pathophysiology performed in collaboration between gastroenterologists, surgeons, oncologists, dieticians, and specialised nurses, as argued in this review.

Cryptoglandular anal fistulas (AF) cause recurrent anal abscesses and patients risk multiple surgeries due to low healing rates of sphincter-saving procedures. Knowledge of anal anatomy and imaging with MRI or endoanal sonography is crucial to classify AF as simple or complex depending on risk of anal incontinence after fistulotomy as summarised in this review. Fistulotomy has healing rates of > 90%, risks incontinence, and the procedure is reserved for simple fistulas. Complex AF are treated with a draining seton and then with sphincter-saving procedures which have long-term healing rates of about 50%.

Patients suffering from multiple sclerosis (MS) often experience bothersome symptoms from the gastrointestinal system and the urinary tract, and they may suffer from sexual dysfunction. These problems can diminish quality of life, and therefore it is important that they are addressed and treated whenever possible. Unfortunately, a limited body of research in the area suggests that this is not always the case, possibly because neither patients nor medical professionals bring up the issues during consultations. More studies are needed to further elucidate the situation.

Neurogenic bladder and bowel dysfunction are among the major problems faced by patients with spinal cord injury and myelomeningocele. New treatment modalities enforcing more natural patient control of voiding and defecation are therefore appealing. We present a historical review of crossover surgery as treatment for such deficiencies and, further, describe the principles as well as the documentation for modern surgical intervention in the form of a somato-autonomic reflex arch.

Urinary and anal incontinence are prevalent in pregnant and parturient women. Pelvic floor muscle training is frequently employed for prevention and treatment. A recent Cochrane review is discussed. Fifteen studies with a total of 6,181 women were included. Pregnant women without urinary incontinence experienced a reduction of the risk of developing urinary incontinence in later pregnancy or post partum. Peripartum patients with urinary and anal incontinence experienced a reduction of their symptoms following training.

Introduction: The aim was to determine the incidence of anal incontinence, recurrence rate and patient satisfaction after using slow-cutting setons for transsphincteric anal fistula repair., Material and Methods: A retrospective study with prospective follow up in 58 patients who had undergone surgery for transsphincteric perianal fistulas with a slow-cutting seton. A total of 17 patients were excluded or lost in the follow up period. A questionnaire was send to 41 cases to the severity of incontinence for gas, liquid and stool according to the Wexner-score. Recurrence rate, sick leave and satisfaction with the treatment were estimated., Results: The questionnaire was returned from 34 patients. In all 23 men and 11 women had the seton tightened for the first time after a mean period of 32 days. The mean number of tightenings was five (range: 2-9). The mean duration of treatment was 256 days (range: 61-634). A total of four patients (12%) experienced recurrence. Twenty-one patients (61,7%) had a Wexner score of one or more. Eight patients (23,5%) scored more than four. A total of 28 patients (82%) were 75-100% satisfied with the treatment. Two patients (6%) were absolutely dissatisfied, and were considered failures. We found no association between the reported satisfaction with the treatment and the degree of incontinence., Conclusion: Despite a very high level of satisfaction among the patients, the high rate of incontinence suggests that other non-invasive techniques should be used as first-line treatment of anal fistulas. In cases where multiple attempts at repair have failed, the slow-cutting seton may be the best option.

Introduction: An analysis of the treatment of faecal incontinence in a surgical specialist practice with a particular interest in this disorder., Material and Methods: From May 2003 to December 2005, a total of 61 patients, 49 women and 12 men with a median age of 72 and 67 years, respectively, were referred for diagnosis and treatment of faecal incontinence. The median Wexner incontinence score was 11 and median quality of life score, on a visual analogue scale ranging from 0 to 10, was 5. Treatment included surgical correction of recto-anal mucosal prolapse and grade 3 to 4 haemorrhoids, medical treatment and sphincter training. Patients were followed-up by a questionnaire after a median period of 23 months (range: 18-31)., Results: Six patients were immediately referred for hospital treatment. Ten patients in whom the result of conservative treatment was unsatisfactory were referred for treatment in specialized colorectal departments after 3-11 months. A total of 41 of the 45 patients returned the questionnaire. The median Wexner incontinence score fell from 11 to 5 (p < 0,01) and the median quality of life score dropped from 5 to 2 (p < 0,01). A total of 38 of the 51 patients who underwent conservative treatment were satisfied with the result and did not request referral to hospital for further treatment (75%; 95% confidence limit: 60-86)., Conclusion: Patients suffering from a moderate degree of faecal incontinence which is not obviously of traumatic origin, including childbirth, may be treated conservatively with a satisfactory result in a surgical specialist practice with special interest in this disorder.

In this study we report late bladder, gastrointestinal and sexual dysfunctions in 23 patients following radical radiotherapy (66Gy-70Gy/33-35fx, 5 fx/week) for prostate cancer. We interviewed the subjects by telephone and compared the results with those of 45 healthy population controls. In general, the patients' bladder function was well preserved. However, compared with the population controls, significantly more patients reported dysuria and hematuria. Twenty-six percent of the patients reported moderate distress from the gastrointestinal tract. Fecal urgency, incontinence and the use of sanitary pads, as well as diarrhoea, and blood and mucous were significantly more common among the patients. Thirty-nine percent of the patients reported moderate or worse distress upon sexual activity, and significantly more patients suffered from erectile impotence.

Background: The aim of this study was to evaluate the rate of complications and the functional result after construction of a coloanal J pouch during low anterior resection of the rectum for cancer., Design: A retrospective study of medical records and interviews with patients at follow-up., Results: 32 patients were followed-up for a median of 28 months (range 12-82 months). Two patients (6%) developed anastomotic leakage, one of whom died. Two patients developed rectovaginal fistula, one of whom was given a permanent colostomy. One patient died from complications after closure of the diverting ileostomy. In two patients, local cancer recurred and four died from distant metastases. At follow-up, the frequency of bowel movements was median 2/24 h (range 0.3-4). Three of 29 (10%) experienced intermittent incontinence, whereas none complained of evacuation problems., Discussion: The complication rate was as expected after low anterior rectal resection, but there were unexpected severe complications after closure of the diverting stoma. The functional results were satisfactory and the construction of a colonic J pouch is recommended during low rectal resection, if the defecation pattern and the quality of life is to improve, especially within the first postoperative year.

Anal sphinctre repair for obstetric sphinctre lesion was performed on 24 patients younger than 40 years and on 14 patients older than 40 years. Twenty patients younger than 40 years (83%; 95% confidence interval: 63-95) became continent compared to six (43%; 18-71) among women over the age of 40. Results of anorectal physiological examination including pudendal nerve terminal motor latency had no prognostic value. It is concluded that older females have a poorer outcome of anal sphinctre repair for obstetric trauma compared with younger females.

The Enema Continence Catheter (ECC) consists of a rectal catheter with an inflatable balloon. The balloon keeps the catheter in the rectum, while enemas are administered. Results from 25 adult patients and 12 children treated with the ECC were evaluated by telephone interviews or by information drawn from patient records. The ECC reduced the frequency of incontinence episodes in four of nine (44%) adult patients suffering from faecal incontinence due to spinal cord lesions, myelomeningocele, complicated anal sphincter lesions or anorectal surgery and irradiation therapy. Among 16 adult patients suffering from constipation or obstructed defecation, the ECC reduced symptoms in three (19%). Furthermore, the ECC procedure reduced symptoms in 10 of 11 (91%) children with colorectal dysfunction, mainly due to spina bifida. In conclusion, the ECC can reduce symptoms in most children suffering from faecal incontinence or constipation, and in some adults with faecal incontinence. However, the method is less effective among adults with constipation or obstructed defecation.

The aim of the study was to assess the long term impact of obstetric anal sphincter rupture on the frequency of anal and urinary incontinence, and identify factors to predict patients at risk. In 94 consecutive women who had sustained an obstetric anal sphincter rupture, anal manometry, anal sphincter electromyography and pudendal nerve terminal motor latency at three months post partum was performed. A questionnaire regarding incontinence was sent between two to four years post partum. Forty-two percent of responders had anal incontinence, 32% had urinary and anal incontinence. Overall, 56% of the women had incontinence symptoms. The occurrence of anal incontinence was associated with pudendal nerve terminal motor latencies > 2.0 milliseconds and the occurrence of urinary incontinence was associated with the degree of rupture, the use of vacuum extraction and previous presence of urinary incontinence. Thirty-eight percent of the women with incontinence wanted treatment, but only a few had sought medical advice.

Low anterior resection (LAR) with mesorectal excision for adenocarcinoma of the rectum leads to low colorectal or coloanal anastomosis, and often poor functional results. Increased stool frequency and urge are common after the operation, and some have anal incontinence. Construction of a neo-rectum, in the form of a colonic J-pouch improves the functional results to some extent. Patients with a colonic J-pouch have significantly lower stool frequency and perhaps also fewer symptoms of urge and incontinence than patients with a straight coloanal anastomosis. If part of the rectum is preserved, the benefit of a pouch is doubtful. The overall quality of life after the operation in patients with a J-pouch is not different from quality of life in patients with a straight coloanal anastomosis. Patients with a pouch may have trouble emptying the reservoir, this is less pronounced if the pouch is shortened to 5 cm. It is not proved with certainty that patients with a colonic J-pouch have fewer anastomotic leakages than patients with a straight coloanal anastomosis. It is concluded that with an anastomotic height below 5 cm a pouch apparently improves the functional results after LAR for adenocarcinoma of the rectum, while the benefit of a pouch above this anastomotic height is doubtful.

An observational study of 144 (mean age 50 [range 45-57] years) perimenopausal women randomly selected from the National Register was conducted in order, to study long term effects of vaginal deliveries on anorectal function. The mean number of vaginal deliveries was two (range 0-6). Measurements were perineal position at rest and during straining, anal mucosa electrosensitivity, maximum resting pressure, maximum squeeze pressure of the anal sphincters, and pudendal nerve terminal motor latency. All tests were performed by a single investigator (AMR) who had no knowledge of the subject's parity. Increasing parity correlated with a lowered perineal position at rest (correlation coefficient (r) = 0.26, p = 0.003) and during straining (r = 0.24, p = 0.006), an increased threshold of anal sensibility (r = 0.22, p = 0.008), and an increased pudendal nerve terminal motor latency (r = 0.27, p = 0.002). No effect of parity on the maximum resting pressure (r = 0.06, p = 0.70) and maximum squeeze pressure (r = 0.06, p = 0.36) was found. The number of vaginal deliveries only accounted for a minor fraction of the total variability (between 3.6-5.7%). It is concluded that repeated vaginal deliveries have a long term adverse effect on anorectal function in a population of randomly selected healthy perimenopausal women.

Thirty-eight women with anal sphincter rupture during childbirth were followed for three to 12 months. Fourteen patients presented with continence disturbances, nine to solid or fluid faeces and five to gas. Incontinence was present in nine patients three months after childbirth. Anal manometry and anal electromyography were performed on the patients three to five days after delivery and repeated at three, six and twelve months after childbirth. Manometry and electromyography were performed on 16 control subjects and 24 primiparous control patients who were investigated three to five days and three months after delivery. Anal manometry and anal electromyography showed significant differences between both incontinent and continent patients compared to control subjects and primiparous control patients. Primiparous control patients had decreased squeeze pressure as well as decreased electromyographic activity during the first days after delivery compared to control subjects. After three months no differences were found. Continence disturbances are frequent after sphincter rupture and these patients should be monitored after delivery and those with persisting incontinence offered sphincter repair.

Endosonography gives detailed information on the internal and external anal sphincters. The goals of this study were to evaluate findings on anal endosonography in patients with anal incontinence and to study the value of endosonography for selecting the most effective surgical treatment. Forty-eight patients with incontinence for either gas (17 patients) or faeces (31 patients) were studied. Nineteen patients had idiopathic incontinence, 29 were incontinent due to previous obstetrical or surgical trauma. Endosonography and measurement of anal canal pressures were performed in all patients, 40 had needle electromyography. The endosonograms were evaluated without knowledge of the clinical findings and correlated with the results of needle electromyography, with the anal pressures, and to the type of surgery subsequently performed. In 30 patients surgery was subsequently planned on the basis of the results of endosonography and the anophysiologic examinations. Endosonograms showed defects in 27 external sphincters, 12 of whom had internal sphincter defects also. One patient had an abnormal thinning of the external sphincter. Eight patients had defects of the internal sphincter as the only finding. Twenty-two of the patients with sonographically detected defects or thinning of the external sphincter had an EMG performed, this showed defects of the external sphincter in 18, four defects in the middle and upper anal canal had not been found. There was no correlation between the sphincteric defects found by endosonography and the anal canal pressures. Sphincter reconstruction was offered to most patients with damage to the external sphincter; patients with isolated defects in the internal sphincter or intact internal and external sphincters were offered a number of other surgical procedures.(ABSTRACT TRUNCATED AT 250 WORDS)