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Background: Anorectal motility disorders such as dyssynergic defecation (DD), faecal incontinence (FI) and anorectal pain affect 40% of the population and are a frequent reason for gastroenterology consultation. They significantly affect the quality of life and lead to psychological distress. Lack of understanding of these problems compounded by a lack of availability and knowledge of diagnostic tools in most medical centres and/or trained physicians has significantly hampered this field., Aims: To discuss the latest advances in pathophysiology, diagnostic tests and therapeutic options for these disorders using an evidence-based approach., Methods: We reviewed the published literature over the past 20 years on DD, FI and anorectal pain and distilled these into a narrative review., Results: A detailed history, prospective stool diary and digital rectal exam, together with diagnostic tests such as anorectal manometry, balloon expulsion test, translumbosacral anorectal magnetic stimulation test for assessing neuropathy, defecography and anal ultrasound, can provide detailed mechanistic and structural information. Such knowledge can pave the way for a meaningful and pathophysiologic-based management approach. This could include biofeedback therapy for DD or FI, sensory training for rectal hyposensitivity or sensory adaptation training for rectal hypersensitivity or sphincter bulking agents or neuromodulation therapies. These treatments are effective and safe., Conclusions: Anorectal motility disorders are common, but either less well recognized or poorly managed by most gastroenterologists. Equipped with the practical and up-to-date knowledge provided in this review, physicians could provide improved health care for these patients., (© 2024 John Wiley & Sons Ltd.)

Background: Low anterior resection syndrome (LARS) is a distressing condition that affects approximately 25-80% of patients following surgery for rectal cancer. LARS is characterized by debilitating bowel dysfunction symptoms, including fecal incontinence, urgent bowel movements, and increased frequency of bowel movements. Although biofeedback therapy has demonstrated effectiveness in improving postoperative rectal control, the research results have not fulfilled expectations. Recent research has highlighted that stimulating the pudendal perineal nerves has a superior impact on enhancing pelvic floor muscle function than biofeedback alone. Hence, this study aims to evaluate the efficacy of a combined approach integrating biofeedback with percutaneous electrical pudendal nerve stimulation (B-PEPNS) in patients with LARS through a randomized controlled trial (RCT)., Methods and Analysis: In this two-armed multicenter RCT, 242 participants with LARS after rectal surgery will be randomly assigned to undergo B-PEPNS (intervention group) or biofeedback (control group). Over 4 weeks, each participant will undergo 20 treatment sessions. The primary outcome will be the LARS score. The secondary outcomes will be anorectal manometry and pelvic floor muscle electromyography findings and the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire-Colorectal 29 (EORTC QLQ-CR29) scores. Data will be collected at baseline, post-intervention (1 month), and follow-up (6 months)., Discussion: We anticipate that this study will contribute further evidence regarding the efficacy of B-PEPNS in alleviating LARS symptoms and enhancing the quality of life for patients following rectal cancer surgery., Trial Registration: Chinese Clincal Trials Register ChiCTR2300078101. Registered 28 November 2023., (© 2024. The Author(s).)

Background: Faecal incontinence is a highly prevalent and very distressing condition that occurs throughout the entire paediatric age., Aim: To summarise advances in the understanding of the epidemiology, pathophysiology, evaluation and treatment of children with faecal incontinence due to either disorders of gut-brain interaction or organic diseases., Methods: Literature review on prevalence, impact, diagnosis and treatment options for children with faecal incontinence, interspersed with observations from the author's lifelong career focused on evaluation of children with motility disorders., Results: Faecal incontinence in children is most commonly due to unrecognised or insufficiently treated functional constipation with overflow incontinence. Non-retentive faecal incontinence (NRFI) is probably more common than previously thought and is particularly challenging to treat. Organic diseases such as anorectal malformations (ARMs), Hirschsprung disease and spinal defects are often associated with faecal incontinence; in these conditions, faecal incontinence has a profound impact on quality of life. Recognition of the different pathophysiologic mechanisms causing the incontinence is essential for a successful treatment plan. A thorough physical examination and history is all that is needed in the diagnosis of the causes of faecal incontinence related to disorders of gut-brain interaction. Colonic transit studies or x-rays may help to differentiate retentive from NRFI. Manometry tests are helpful in determining the mechanisms underlying the incontinence in children operated on for ARMs or Hirschsprung diseases. Multiple behavioural, medical and surgical interventions are available to lessen the severity of faecal incontinence and its impact on the daily life of affected individuals., Conclusions: Recent advances offer hope for children with faecal incontinence., (© 2023 John Wiley & Sons Ltd.)

Introduction: Robot-assisted laparoscopic radical prostatectomy (RALP) is a common procedure for the treatment of localised prostate cancer. Anorectal symptoms such as fecal incontinence (FI), rectal urgency or disturbed defecation have been reported after the operation. Anorectal function is dependent on the integrity of anal and pelvic nerves and muscles, rectal sensory function as well as rectal reservoir function. The aim of this study was to investigate the potential influence of RALP on anorectal physiological function and bowel symptoms., Materials and Methods: In this pilot study, 29 patients with localised prostate cancer scheduled for RALP were included. Anorectal physiology was used to measure rectal sensitivity and reservoir function as well as anal sphincter pressures. Bowel symptoms were measured by a bowel function questionnaire and a 2-week bowel function diary. Measurements were done before the operation and repeated at 6 months after the operation., Results: The study observed a significant postoperative increase in rectal sensory threshold for rectal balloon distention, from 20 to 40 mmHg, P < 0.001. This change is indicative of a decrease in rectal sensation after RALP. There were no other statistical significant differences in any of the physiological tests performed. Importantly, there was no change in any of the bowel symptoms after surgery., Conclusion: This study showed that RALP may lead to impaired rectal sensory function. This finding did not, however, seem to have any influence on the patients´ postoperative clinical bowel function.

Pelvic floor disorders (PFDs), such as pelvic organ prolapse (POP) and urinary incontinence (UI), severely affect women's quality of life. Among these, stress urinary incontinence (SUI) is the most common, impacting a significant proportion of women. In the US, the lifetime risk of undergoing surgery for UI or POP stands at 20%. Pregnancy-related factors, notably delivery method and UI occurrence during pregnancy, have a potent correlation with PFD onset. The pathophysiology of PFDs during pregnancy is complex, with factors like increased intra-abdominal pressure, changes in bladder neck mobility, and shifts in pelvic floor muscle strength and collagen metabolism playing pivotal roles. PFD risk factors span across pregnancy, labor, and the postnatal phase and include UI or fecal incontinence (FI) during pregnancy, advanced maternal age, elevated BMI, multiple births, instrumental and spontaneous vaginal deliveries, and newborns weighing over 4000 grams. Conversely, Cesarean deliveries are linked with a reduced long-term risk of UI and POP compared to vaginal births. Current prognostic models can predict the likelihood of PFD development based on variables such as delivery method, number of births, and familial history. Preventive measures encompass lifestyle changes like caffeine reduction and weight management, alongside pelvic floor muscle training (PFMT) during pregnancy. Thus, expectant mothers are advised to participate in physical activities, prominently including PFMT.

Introduction: Fatigue of the anal sphincter complex has been demonstrated using high-resolution anorectal manometry (HRAM). However, the fatigability of individual muscles such as the external anal sphincter (EAS) and puborectalis muscles (PRM) has not been described. Vaginal manometry has been used to study contractile activity of the PRM. By applying both modalities, we attempted to differentiate the fatigability between the PRM and the EAS under different exercise conditions., Methods: We studied two groups: group 1, 12 healthy women (21 ± 2.7 years) with HRAM and group 2, 10 healthy (20 ± 3 years) women with vaginal manometry. All subjects performed 40 repetitive contractions with and without an intra-anal resistive load. In group 1, areas under the curve (AUC) of the anal canal high-pressure zone (HPZ) including the caudal and rostral halves were compared. In group 2, the maximum and mean pressures of the vaginal HPZ were compared., Results: The AUC decreased significantly only after repetitive contractions against a resistive load (462 ± 129 vs. 390 ± 131 mmHg-cm, p = 0.02), indicating fatigue. The caudal half (EAS) decreased significantly after contractions against a load (288 ± 75 vs. 239 ± 82 mmHg-cm, p = 0.02), while the rostral half (PRM) did not. The vaginal pressures (PRM) also decreased only after repetitive contractions against a load (maximum pressures, 358 ± 171 vs. 239 ± 109 mmHg, p = 0.02)., Conclusions: The EAS and PRM both exhibit fatigue with contractions only against a resistive load. These findings may guide the development of appropriate exercise regimens to target specific muscles involved in fecal continence., (© 2021 The Authors. Physiological Reports published by Wiley Periodicals LLC on behalf of The Physiological Society and the American Physiological Society.)

Our understanding of human colonic motility, and autonomic reflexes that generate motor patterns, has increased markedly through high-resolution manometry. Details of the motor patterns are emerging related to frequency and propagation characteristics that allow linkage to interstitial cells of Cajal (ICC) networks. In studies on colonic motor dysfunction requiring surgery, ICC are almost always abnormal or significantly reduced. However, there are still gaps in our knowledge about the role of ICC in the control of colonic motility and there is little understanding of a mechanistic link between ICC abnormalities and colonic motor dysfunction. This review will outline the various ICC networks in the human colon and their proven and likely associations with the enteric and extrinsic autonomic nervous systems. Based on our extensive knowledge of the role of ICC in the control of gastrointestinal motility of animal models and the human stomach and small intestine, we propose how ICC networks are underlying the motor patterns of the human colon. The role of ICC will be reviewed in the autonomic neural reflexes that evoke essential motor patterns for transit and defecation. Mechanisms underlying ICC injury, maintenance, and repair will be discussed. Hypotheses are formulated as to how ICC dysfunction can lead to motor abnormalities in slow transit constipation, chronic idiopathic pseudo-obstruction, Hirschsprung's disease, fecal incontinence, diverticular disease, and inflammatory conditions. Recent studies on ICC repair after injury hold promise for future therapies.

Introduction: Pelvic floor disorders (PFD) are gynecologic health problems containing a wide variety of clinical problems; the most prevalent problems are pelvic organ prolapse, fecal incontinence, and urinary incontinence. It is a significant women's health problem for both developed and developing countries. One in five women in Ethiopia experiences at least one major type of pelvic floor disorders. Despite the severity of the problem, due attention was not given, and no study has been conducted on pelvic floor disorders in the Gurage Zone., Objective: To determine the prevalence and associated factors of symptomatic pelvic floor disorders among women living in Gurage Zone, SNNPR, Ethiopia, 2020., Methodology: Community-based cross-sectional study was conducted from February to March 2020 among 542 women residing in the Gurage Zone. A multi-stage sampling method was used to select the participants. Interviewer administered, pretested questionnaires containing questions related to pelvic organ prolapse, urinary, and fecal incontinence was used. The urinary incontinence severity index questionnaire was used to assess the severity of urinary incontinence. Epi-Info x7 was used to record data, and SPSS was used to analyze the data. Binary logistic regression with 95% CI was used to explore the relationship between PFD and other independent variables. After multivariable logistic regression analysis variables with P-value less than 0.05 was used to determine significant association., Result: A total of 542 participants were included in this study. Overall, 41.1% of the participants reported one or more symptoms of pelvic floor disorders. Urinary incontinence had the highest prevalence (32.8%), followed by pelvic organ prolapse (25.5%) and fecal incontinence (4.2%). History of weight lifting >10 Kg (AOR = 3.38; 95% CI: 1.99, 5.72), ≥5 vaginal delivery (AOR = 11.18; 95% CI: 1.53, 81.58), and being in menopause (AOR = 3.37; 95% CI: 1.40, 8.07) were identified as possible contributing factors in the development of a pelvic floor disorders., Conclusion: The prevalence of symptomatic PFD was higher compared to other similar studies in Ethiopia. Heavy weight lifting, repetitive vaginal deliveries and menopause were factors significantly associated with PFD. Expansion of technologies and building basic infrastructures, health education on kegel exercise and promotion of family planning should be considered as a prevention strategy., Competing Interests: The authors have declared that no competing interests exist.

Objective: Pelvic floor muscle contractility (PFMC) may contribute to anal continence. The aim of this study was to assess the association between clinical and sonographic measures of PFMC and anal incontinence (AI) symptoms, after controlling for anal sphincter and levator ani muscle (LAM) trauma., Methods: This was a retrospective study of 1383 women assessed at a tertiary center between 2013 and 2016. All patients underwent an interview, including the St Mark's incontinence score (SMIS) in those who reported AI symptoms, a clinical examination, including assessment of PFMC using the modified Oxford scale (MOS), and four-dimensional translabial ultrasound (TLUS). Sonographic measures of PFMC, i.e. cranioventral shift of the bladder neck (BN) and reduction of anteroposterior (AP) diameter of the levator hiatus, were measured offline using ultrasound volumes obtained at rest and on maximum pelvic floor contraction. The reviewer was blinded to all clinical data., Results: Of the 1383 patients assessed during the study period, seven were excluded due to missing imaging data, leaving 1376 for analysis. Mean age of the participating women was 55 years and mean body mass index was 29 kg/m 2 . AI was reported by 221 (16.1%) women, with a mean SMIS of 11.8. Mean MOS grade was 2.3. On TLUS, mean BN cranioventral shift was 5.9 mm and mean AP diameter reduction was 8.1 mm. LAM avulsion and significant external anal sphincter (EAS) defect were diagnosed in 24.8% and 8.7% patients, respectively. On univariate analysis, sonographic measures of PFMC were not associated with AI. Lower MOS grade was associated with symptoms of AI; however, statistical significance was lost on multivariate analysis., Conclusion: Clinical and sonographic measures of PFMC were not significantly associated with AI symptoms after controlling for EAS and LAM trauma. © 2020 International Society of Ultrasound in Obstetrics and Gynecology., (© 2020 International Society of Ultrasound in Obstetrics and Gynecology.)

Exercises involving pelvic floor muscles including repetitive voluntary contractions of external anal sphincter (EAS) musculature have been used to improve fecal incontinence. Muscle fatigue is a prerequisite for successful strength training. However, muscle fatigue induced by these exercises has not been systematically studied. We aimed to assess the fatigability of EAS muscles during various exercise methods. Twelve nulliparous (21 ± 2.7 yr) women were studied. We evaluated fatigue during 40 repetitive 3-s contractions and 30-s long squeeze contractions both with and without an intra-anal compressible resistant load. The sequence of exercises was randomized. This load was provided by the continence muscles Resistance Exerciser Device. Anal canal pressures were recorded by high-resolution manometry. Exercise against a resistive load showed significant decrease in anal contractile integral (CI) and maximum squeeze pressure during repetitive short squeeze contractions compared with exercise without a load. Linear regression analysis showed a significant negative correlation between anal CI and successive contraction against load, suggesting "fatigue." Similar findings were observed for maximum squeeze pressure (slope with load = -4.2, P = 0.0003, vs. without load = -0.9, P = 0.3). Long squeeze contraction against a load was also more susceptible to fatigue than without a load ( P < 0.0001). In conclusion, repetitive contractions against a compressible load induce fatigue and thus have the potential to strengthen the anal sphincter contractile function than contractions without a load. Fatigue rate in long squeeze contraction exercises with a load is significantly faster than that without a load, also indicating greater effectiveness in inducing muscle fatigue. NEW & NOTEWORTHY Fecal incontinence is a distressing disorder with a mainstay of treatment being pelvic floor muscle exercises. However, none of these exercises has proven occurrence of fatigability, which is an important prerequisite for successful muscle strengthening in rehabilitative exercises. In this study, we proved that we can fatigue the external anal sphincter muscles more efficiently by providing a resistive load during anal repetitive short squeeze contractions and long squeeze contraction exercise.

Introduction: Perineal descent is a phenomenon associated with anorectal dysfunction. It is diagnosed by defecography but subjected to manual measurements on the images/videos and interobserver bias. Fecobionics is a simulated feces for assessing important physiological parameters during defecation. Here, we translate Fecobionics into a new method for estimation of perineal descent based on electronic signals from the embedded inertial measurement units (IMUs)., Methods: A displacement measurement method by a combined zero-velocity update and gravity compensation algorithm from IMUs was developed. The method was verified in a robot model, which mimicked perineal descent motion., Results: The method correlated well with the reference (R = 0.9789) and had a deviation from the peak displacement (range 0.25-2.5 cm) of -0.04 ± 0.498 cm. The method was further validated in 5 human experiments with comparison to the benchmark defecography technology (R = 0.79)., Discussion: The proposed technology is objective, i.e., electronic measurements rather than by fluoroscopy or MRI. The development may impact clinical practice by providing a resource-saving and objective technology for diagnosing perineal descent in the many patients suffering from anorectal disorders. The technology may also be used in colon experiments with Fecobionics and for other gastrointestinal devices containing IMUs such as ingestible capsules like the Smartpill.

Clinicians and patients have traditionally believed that elective cesarean section may protect against certain previously ineluctable consequences of labor, including a plethora of urinary, anorectal and sexual dysfunctions. We aimed to evaluate fecal, urinary and sexual symptoms 6 years postpartum, comparing uncomplicated vaginal delivery and elective cesarean delivery, and to assess their impact on quality of life. We conducted a cross-sectional study to compare perineal functional symptomatology between women having singleton elective cesarean deliveries (eCS) and singleton uncomplicated vaginal deliveries (uVD). Women who delivered 6 years before this study were chosen randomly from our hospital database. This database includes demographic, labor, and delivery information, as well as data regarding maternal and neonatal outcomes, all of which is collected at the time of delivery by the obstetrician. Four validated self-administrated questionnaires were sent by post to the participants: the short forms of the Urogenital Distress Inventory, Incontinence Impact Questionnaire, Wexner fecal incontinence scale, and Female Sexual Function Index. Current socio-demographic details, physical characteristics, obstetrical history and mode of delivery at subsequent births were also registered using a self-reported questionnaire. A total of 309 women with uVD and 208 with eCS returned postal questionnaires. The response rate was 49%. Socio-demographic characteristics and fecal incontinence were similar between groups. After eCS, women reported significantly less urgency urinary incontinence (adjusted Relative Risk 0.55; 95% confidence interval 0.34-0.88) and stress incontinence (adjusted Relative Risk 0.53; 95% confidence interval 0.35-0.80) than after uVD. No difference in total Incontinence Impact Questionnaire score was found between both modes of delivery. Lower abdominal or genital pain (adjusted Relative Risk 1.58; 95% confidence interval 1.01-2.49) and pain related to sexual activity (adjusted Relative Risk 2.50; 95% confidence interval 1.19-5.26) were significantly more frequent after eCS than uVD. Six years postpartum, uVD is associated with urinary incontinence, while eCS is associated with sexual and urination pain.

Background: Fecal incontinence is a disabling condition affecting up to 20% of women., Objective: We investigated fecal incontinence assessment in both inflammatory bowel disease and non-inflammatory bowel disease patients to propose a diagnostic approach for inflammatory bowel disease trials., Methods: We searched on Pubmed, Embase and Cochrane Library for all studies on adult inflammatory bowel disease and non-inflammatory bowel disease patients reporting data on fecal incontinence assessment from January 2009 to December 2019., Results: In total, 328 studies were included; 306 studies enrolled non-inflammatory bowel disease patients and 22 studies enrolled inflammatory bowel disease patients. In non-inflammatory bowel disease trials the most used tools were the Wexner score, fecal incontinence quality of life questionnaire, Vaizey score and fecal incontinence severity index (in 187, 91, 62 and 33 studies). Anal manometry was adopted in 41.2% and endoanal ultrasonography in 34.0% of the studies. In 142 studies (46.4%) fecal incontinence evaluation was performed with a single instrument, while in 64 (20.9%) and 100 (32.7%) studies two or more instruments were used. In inflammatory bowel disease studies the Wexner score, Vaizey score and inflammatory bowel disease quality of life questionnaire were the most commonly adopted tools (in five (22.7%), five (22.7%) and four (18.2%) studies). Anal manometry and endoanal ultrasonography were performed in 45.4% and 18.2% of the studies., Conclusion: Based on prior validation and experience, we propose to use the Wexner score as the first step for fecal incontinence assessment in inflammatory bowel disease trials. Anal manometry and/or endoanal ultrasonography should be taken into account in the case of positive questionnaires.

There is a need for a lower cost manometry system for assessing anorectal function in primary and secondary care settings. We developed an index finger-based system (termed "digital manometry") and tested it in healthy volunteers, patients with chronic constipation, and fecal incontinence. Anorectal pressures were measured in 16 participants with the digital manometry system and a 23-channel high-resolution anorectal manometry system. The results were compared using a Bland-Altman analysis at rest as well as during maximum squeeze and simulated defecation maneuvers. Myoelectric activity of the puborectalis muscle was also quantified simultaneously using the digital manometry system. The limits of agreement between the two methods were -7.1 ± 25.7 mmHg for anal sphincter resting pressure, 0.4 ± 23.0 mmHg for the anal sphincter pressure change during simulated defecation, -37.6 ± 50.9 mmHg for rectal pressure changes during simulated defecation, and -20.6 ± 172.6 mmHg for anal sphincter pressure during the maximum squeeze maneuver. The change in the puborectalis myoelectric activity was proportional to the anal sphincter pressure increment during a maximum squeeze maneuver (slope = 0.6, R2 = 0.4). Digital manometry provided a similar evaluation of anorectal pressures and puborectalis myoelectric activity at an order of magnitude less cost than high-resolution manometry, and with a similar level of patient comfort. Digital Manometry provides a simple, inexpensive, point of service means of assessing anorectal function in patients with chronic constipation and fecal incontinence., Competing Interests: WDC and JAAM are two of three co-inventors of “Digital manometry finger-mountable sensor device” WIPO (PCT) WO02013090681 (2012). This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Colon and rectal disorders can be functional and inflammatory. This is the second paper of a three-part series14 and will focus on the diagnosis and treatment of rectal prolapse, fecal incontinence and inflammatory bowel disease., (Copyright 2020 by the Missouri State Medical Association.)

Background: After low anterior resection (LAR), up to 90% of patients develop anorectal dysfunction. Especially fecal incontinence has a major impact on the physical, psychological, social, and emotional functioning of the patient but also on the Dutch National Healthcare budget with more than €2000 spent per patient per year. No standardized treatment is available to help these patients. Common treatment nowadays is focused on symptom relief, consisting of lifestyle advices and pharmacotherapy with bulking agents or antidiarrheal medication. Another possibility is pelvic floor rehabilitation (PFR), which is one of the most important treatments for fecal incontinence in general, with success rates of 50-80%. No strong evidence is available for the use of PFR after LAR. This study aims to prove a beneficial effect of PFR on fecal incontinence, quality of life, and costs in rectal cancer patients after sphincter-saving surgery compared to standard treatment., Methods: The FORCE trial is a multicenter, two-armed, randomized clinical trial. All patients that underwent LAR are recruited from the participating hospitals and randomized for either standard treatment or a standardized PFR program. A total of 128 patients should be randomized. Optimal blinding is not possible. Stratification will be done in variable blocks (gender and additional radiotherapy). The primary endpoint is the Wexner incontinence score; secondary endpoints are health-related and fecal-incontinence-related QoL and cost-effectiveness. Baseline measurements take place before randomization. The primary endpoint is measured 3 months after the start of the intervention, with a 1-year follow-up for sustainability research purposes., Discussion: The results of this study may substantially improve postoperative care for patients with fecal incontinence or anorectal dysfunction after LAR. This section provides insight in the decisions that were made in the organization of this trial., Trial Registration: Netherlands Trial Registration, NTR5469, registered on 03-09-2015. Protocol FORCE trial V18, 19-09-2019. Sponsor Radboud University Medical Center, Nijmegen.

Cardiac loops have been used extensively to study myocardial function. With changes in cardiac pump function, loops are shifted to the right or left. Functional luminal imaging probe (FLIP) recordings allow for loop analysis of the anal sphincter and puborectalis muscle (PRM) function. The goal was to characterize anal sphincter area-pressure/tension loop changes in fecal incontinence (FI) patients. Fourteen healthy subjects and 14 patients with FI were studied. A custom-designed FLIP was placed in the vagina and then in the anal canal, and deflated in 20-ml steps, from 90 to 30 ml. At each volume, subjects performed maximal voluntary squeezes. Area-pressure (AP) and area-tension (AT) loops were generated for each squeeze cycle. Three-dimensional ultrasound imaging of the anal sphincter and PRM were obtained to determine the relationship between anal sphincter muscle damage and loop movements. With the increase in bag volume, AP loops and AT loops shifted to the right and upward in normal subjects (both anal and vaginal). The shift to the right was greater, and the upward movement was less in FI patients. The difference in the location of AP loops and AT loops was statistically significant at volumes of 50 ml to 90 ml ( P < 0.05). A similar pattern was found in the vaginal loops. There is a significant relationship between the damage to the anal sphincter and PRM, and loop location of FI patients. We propose AP and AT loops as novel ways to assess the anal sphincter and PRM function. Such loops can be generated by real-time measurement of pressure and area within the anal canal. NEW & NOTEWORTHY We describe the use of area-pressure (AP) and area-tension (AT)-loop analysis of the anal sphincters and puborectalis muscles in normal subjects and fecal incontinent patients using the functional luminal imaging probe (FLIP). There are differences in the magnitude of the displacement of the loops with increase in the FLIP bag volume between normal subjects and patients with fecal incontinence. The latter group shifts more to the right in AP and AT space.

Cerebral choline metabolism is crucial for normal brain function, and its homoeostasis depends on carrier-mediated transport. Here, we report on four individuals from three families with neurodegenerative disease and homozygous frameshift mutations (Asp517Metfs*19, Ser126Metfs*8, and Lys90Metfs*18) in the SLC44A1 gene encoding choline transporter-like protein 1. Clinical features included progressive ataxia, tremor, cognitive decline, dysphagia, optic atrophy, dysarthria, as well as urinary and bowel incontinence. Brain MRI demonstrated cerebellar atrophy and leukoencephalopathy. Moreover, low signal intensity in globus pallidus with hyperintensive streaking and low signal intensity in substantia nigra were seen in two individuals. The Asp517Metfs*19 and Ser126Metfs*8 fibroblasts were structurally and functionally indistinguishable. The most prominent ultrastructural changes of the mutant fibroblasts were reduced presence of free ribosomes, the appearance of elongated endoplasmic reticulum and strikingly increased number of mitochondria and small vesicles. When chronically treated with choline, those characteristics disappeared and mutant ultrastructure resembled healthy control cells. Functional analysis revealed diminished choline transport yet the membrane phosphatidylcholine content remained unchanged. As part of the mechanism to preserve choline and phosphatidylcholine, choline transporter deficiency was implicated in impaired membrane homeostasis of other phospholipids. Choline treatments could restore the membrane lipids, repair cellular organelles and protect mutant cells from acute iron overload. In conclusion, we describe a novel childhood-onset neurometabolic disease caused by choline transporter deficiency with autosomal recessive inheritance., (© The Author(s) (2019). Published by Oxford University Press on behalf of the Guarantors of Brain. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Obstetric anal sphincter injuries (OASIS) are associated with sexual dysfunction and a lower likelihood of sexual activity in the postpartum period. The aim of the present study was to compare coital resumption and the variables influencing this activity after delivery in women with and without a history of obstetric anal sphincter injury (OASIS) and according to the mode of delivery., Methods: A prospective, observational, case-control study was performed at 6 months postpartum in 318 women: 140 with a history of primary repaired OASIS and 178 women without OASIS. Demographic and obstetric data, breastfeeding, and symptoms of urinary and anal incontinence were collected. Patients were asked about coital resumption and completed the validated specific Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 (PISQ-12). Continuous and non-continuous variables were compared using ANOVA and the Fisher exact tests, respectively. A multivariate logistic regression model and a multiple regression analysis were constructed to assess the impact of demographic and clinical variables on the percentage of coital resumption and on the PISQ-12 score, respectively., Results: After a spontaneous delivery (SD), patients without OASIS showed a higher percentage of coital resumption than those with OASIS (98% vs. 77%; p = 0.003), and the PISQ-12 score was also higher (p < 0.001). PISQ-12 score was better in women with SD compared to those with operative vaginal delivery (OVD)(p < 0.001), independently of the history of OASIS. Current breastfeeding, a higher Wexner score and OVD negatively influenced the PISQ-12 score., Conclusions: After SD, women with OASIS resumed coital activity later than women without OASIS. Women with OVD resumed coital activity later, and had a lower PISQ-12 score than women with SD.

Introduction: Defecation is a complex process that can be easily disturbed. Defecatory disorders may be diagnosed using specialized investigation, including anorectal manometry (ARM) and the balloon expulsion test (BET). Recently, we developed a simulated stool named Fecobionics that integrates several tests and assesses pressures, orientation, and bending during evacuation. The aim was to evaluate the feasibility and performance of Fecobionics for assessing defecatory physiology in normal subjects., Methods: Physiological expulsion parameters were assessed in an interventional study design. The 10-cm-long Fecobionics probe contained pressure sensors at the front and rear and inside a bag and 2 motion processor units. The bag was distended in the rectum of 20 presumed normal subjects (15 female/5 male) until urge to defecate. ARM-BET was also performed. Three subjects used +2 minutes to evacuate BET, and 1 subject had a high fecal incontinence score. Therefore, the normal group consisted of 16 subjects (13 female/3 male aged 25-78 years)., Results: All subjects reported that Fecobionics evacuation was similar to normal defecation. Fecobionics expulsion pressure signatures demonstrated 5 phases, reflecting rectal pressure, anal relaxation, and anal passage. Preload-afterload loop diagrams demonstrated clockwise contraction cycles. The expulsion duration for BET and Fecobionics was 16 ± 2 and 23 ± 5 seconds (P > 0.2), respectively. The duration of the Fecobionics and BET expulsions was associated (P < 0.001). The change in bending of Fecobionics during defecation was 40 ± 3°., Discussion: Fecobionics obtained reliable data under physiological conditions. Agreement was found for comparable variables between ARM-BET and Fecobionics but not for other variables. The study suggests that Fecobionics is safe and effective in evaluation of key defecatory parameters.

Background: Bowel and bladder problems affect more than 50% of people with Multiple Sclerosis (MS). These problems have a large impact on quality of life and place a significant burden on health systems., Objectives: This study aimed to ascertain the frequency of bladder and bowel problems in a select Australian MS cohort and to investigate the relationships between level of disability, bladder and bowel problems, and fatigue., Methods: Questionnaires on the nature and severity of MS symptoms were distributed to clients attending an Australian MS centre. Log-binomial regression and multiple linear regression models were used to investigate relationships between disability, fatigue, and bladder and bowel problems., Results and Conclusions: Of 167 questionnaires distributed, 136 were completed. Bladder problems were reported by 87 (74.4%) respondents, whilst 66 (48.9%) experienced functional constipation and 43 (31.9%) faecal incontinence. This frequency in our select Australian MS population is similar to that reported globally. There was a significant correlation between level of disability and: bladder problems (p = 0.015), faecal incontinence (p = 0.001), fatigue (p<0.001) and constipation (p = 0.016, relative risk: 1.16). Further investigation into the causal relationships between various MS symptoms may be beneficial in the development of novel therapeutic strategies for people with MS., Competing Interests: PH and TJ are employees of MS Limited. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Background & Aims: Inflammatory bowel disease (IBD) scoring systems combine patient-reported data with physicians' observations to determine patient outcomes, but these systems are believed to have limitations. We used real-world data from a large IBD cohort in Switzerland to compare results between patients and healthcare professionals from scoring systems for Crohn's disease (CD) and ulcerative colitis (UC)., Methods: We collected data from the Swiss IBD cohort, beginning in 2006, using 2453 reports for 1385 patients (52% female, 58% with CD). During office visits, physicians asked patients about signs and symptoms and recorded their answers (health care professional-reported outcomes). On a later date, patients received a questionnaire at home (independently of the medical visit), complete it, and sent it back to the data center. Patients also completed the short form 36 and IBD quality of life (QoL) questionnaires. We calculated Cohen's kappa (κ) statistics to assess the level of agreement in scores between patients and health care professionals (Δt between reports collected less than 2 months apart). We used Spearman correlation coefficients (ρ) to compare general well-being (GWB) and QoL scores determined by patients vs health care professionals. Our primary aim was to investigate the overall and individual level of agreement on signs and symptoms reported by health care professionals vs patients., Results: The best level of agreement (although moderate) was observed for number of stools last week in patients with CD (κ = 0.47), and nocturnal diarrhea in patients with UC (κ = 0.52). Agreement was low on level of abdominal pain (κ = 0.31 for patients with CD and κ = 0.37 for patients with UC) and GWB (κ = 0.23 for patients with CD and κ = 0.26 for patients with UC). Patients reported less severe abdominal pain and worse GWB (CD) or better GWB (UC) than that determined by health care professionals. Patient self-rated GWB correlated with IBD quality of life (ρ = 0.68 for patients with CD and ρ = 0.70 for patients with UC) and SF-36 physical scores (ρ = 0.55 for patients with CD and ρ = 0.60 for patients with UC); there was no correlation between health care professional-rated GWB and QoL., Conclusions: In a comparison of patient vs health care provider-reported outcomes in a Swiss IBD cohort, we found that health care professionals seem to misinterpret patients' complaints. Patients self-rated GWB correlated with QoL scores, indicating that reporting GWB in a single question is possible and relevant, but can vary based on how the data are collected., (Copyright © 2019 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background: Low-type anorectal malformations (ARMs) are considered benign; however, in China, data regarding such conditions are limited. Thus, this study aimed to assess the middle-term bowel functions and quality of life (QOL) among children with low-type ARM., Methods: Children > 3 years of age who underwent treatment for low-type ARM (vestibular fistula [VF] and perineal fistula [PF]) during 2013 and healthy children were included. The children were interviewed during their outpatient visits. The primary outcome measures were bowel function, as assessed using the Baylor Continence Scale (BCS), and QOL, as measured using the Pediatric Quality of Life Inventory (PedsQL 4.0)., Results: A total of 82 patients responded; mean patient age was 6.8 (range, 3-12) years. Mean BCS score in the control group (7.94 ± 4.74) was significantly lower than that in the VF (18.69 ± 11.11, P < 0.001) and PF (15.47 ± 6.50, P < 0.001) groups. However, there were no differences in PedsQL 4.0 scores among the groups. The patients scored the lowest for emotional function and the highest for physical function. Nearly all measurements of QOL significantly decreased with increased BCS score., Conclusions: Children with low-type ARM can achieve good bowel control and QOL. However, although ARMs are benign, several children with this condition suffer from anal function problems that affect QOL. Redo operations, mislocated anus, and incorrect constipation treatment are the iatrogenic causes of fecal incontinence.

Objectives: This study aims to compare pelvic floor muscle (PFM) functions in midwifes and nurses of reproductive age with and without pelvic floor dysfunction (PFD) and investigate the relationship between PFM function and the number, type and symptoms of PFDs., Materials and Methods: 82 midwifes and nurses of reproductive age with (n = 51) and without PFD (n = 31) participated in the study. PFM function was assessed by digital palpation using PERFECT scale. Gynecological examination, ultrasonography, disease-specific questionnaires, questions and tests were used to assess symptoms of PFD. PFD was assessed in terms of risk factors, urinary incontinence, fecal incontinence, pelvic organ prolapse (POP), pelvic pain and sexual dysfunctions., Results: Power parameter of PERFECT scheme was significantly lower in subjects with PFD compared to Non-PFD group (p = 0.002). 41% of the subjects with Power 5 PFM strength in PFD group were diagnosed as stage 1 POP, 5.8% as stage 2 POP, 15.7% of urge incontinence, 23.3% of stress incontinence and 10.5% of mixed incontinence. Both urinary incontinence and POP were detected in 15.7% of them. Among all subjects, incontinence symptoms decreased whereas POP and sexual function did not change as PFM increased. PFM strength was negatively correlated with the number of PFD (p = 0.002, r = -0.34). The type of dysfunction did not correlate with PFM strength (p > 0.05)., Conclusion: PFM strength only affects of urinary incontinence sypmtoms among all PFDs in midwifes and nurses of reproductive age. PFM strength may not be the main factor in the occurrence of PFDs as pelvic floor does not consist solely of muscle structure. However, it strongly affects the number of dysfunctions. Therefore, PFM training should be performed to prevent the occurrence of extra dysfunctions in addition to the existing ones even if it does not alter the symptoms., (Copyright © 2019. Published by Elsevier B.V.)

Introduction: Children with functional constipation frequently present with alterations in rectal compliance and the urge-to-defecate sensation that can be evaluated through anorectal manometry (ARM). In the present study, we evaluated the usefulness of the parameters obtained through ARM in children with retentive fecal incontinence (RFI)., Materials and Methods: Children with functional constipation, aged 4 to 17years, that underwent ARM were included in the study., Results: Of the 35 children evaluated, 21 presented with functional constipation and 14 had functional constipation and RFI. The children with both constipation and RFI tolerated greater volumes of air insufflation for triggering the urge to defecate and reaching maximum tolerance of pain, compared with the children that did not have RFI. We identified the cutoff point of 135ml of air as the maximum tolerance sensation for distinguishing children with RFI., Conclusions: Maximum tolerance of pain was the most useful parameter for evaluating RFI in children with functional constipation., (Copyright © 2019 Asociación Mexicana de Gastroenterología. Publicado por Masson Doyma México S.A. All rights reserved.)

Introduction: Fecal incontinence (FI) is a common complaint and is often associated with diarrhea and urgency. Foods high in fermentable oligo-, di-, and mono-saccharides and polyols (FODMAP) cause symptoms of diarrhea and urgency. Therefore, this study assesses the impact of a low FODMAP diet on the occurrence of FI due to loose stool., Methods: This study is a retrospective chart review of patients with FI seen in the Michigan Bowel Control Program clinic between August 2012 and December 2017. Patients who had FI with loose stool without red flag signs and who were recommended a low FODMAP diet and underwent formal dietary instruction with a Michigan Medicine dietician were included., Results: Sixty-five patients with FI who underwent formal dietary teaching were included in this study. Eighty-eight percent of the patients were white, and 87% were women with a mean age of 62 years (±14 years). Additionally, the chart review showed that 35% of the patients had FI daily, 21.5% had FI weekly, and 5% had FI monthly. About 64.6% of the patients (42) had reported a reduction in their FI symptoms with the low FODMAP diet. There was no demographic or clinical characteristic that predicted the response to a low FODMAP diet., Discussion: In this case series, dietary manipulation with a low FODMAP diet was a useful tool to treat patients who suffer from FI due to loose stool. Further confirmatory, prospective randomized controlled trials are required to see the true efficacy of a low FODMAP diet in patients who suffer with FI.

Background: Although numerous treatments exist for fecal incontinence (FI), no consensus exists on the best treatment strategy. The aim was to review the literature and to compare the clinical outcomes and effectiveness of treatments available for FI., Materials and Method: A systematic literature review was performed, from inception to May 2018, of the following databases: MEDLINE, EMBASE, Science Citation Index Expanded, Cochrane Library. The search terms used were "faecal incontinence" and "treatment". Only randomized controlled trials (RCTs) comparing treatments for FI were considered. A Bayesian network meta-analysis was performed using the Markov chain Monte Carlo method., Result: Forty-seven RCTs were included comparing 37 treatments and reporting on 3748 participants. No treatment ranked best or worst with high probability for any outcome of interest. No significant difference was identified between treatments for frequency of FI per week, or in changing the resting pressure, maximum resting pressure, squeeze pressure, and maximum squeeze pressure. Radiofrequency resulted in more adverse events compared to placebo. Sacral nerve stimulation (SNS) and zinc-aluminium improved the fecal incontinence quality of life questionnaire (FIQL) lifestyle, coping, and embarrassment domains compared to placebo. Transcutaneous posterior tibial nerve stimulation (TPTNS) improved the FIQL embarrassment domain compared to placebo. Autologous myoblasts and zinc-aluminium improved the FIQL depression domain compared to placebo. SNS, artificial bowel sphincter (ABS), and zinc-aluminium significantly improved incontinence scores compared to placebo. Injection of non-animal stabilized hyaluronic acid/dextranomer (NASHA/Dx) resulted in more patients with ≥50% reduction in FI episodes compared to placebo., Conclusion: SNS, ABS, TPTNS, NASHA/Dx, zinc-aluminium, and autologous myoblasts resulted in isolated improvements in specific outcomes of interest. No difference was identified in incontinence episodes, no treatment ranked best persistently or persistently improved outcomes, and many included treatments did not significantly benefit patients compared to placebo. Large multicentre RCTs with long-term follow-up and standardized inclusion criteria and outcome measures are needed., (Copyright © 2019 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Background & Aims: The neuropathophysiology of fecal incontinence (FI) is incompletely understood. We examined the efferent brain-anorectal and spino-anorectal motor-evoked potentials (MEP) to characterize the locus of neuronal injury in patients with FI., Methods: We performed bilateral transcranial, translumbar, and transsacral magnetic stimulations in 27 patients with FI (19 female) and 31 healthy individuals (controls, 20 female) from 2015 through 2017. MEPs were recorded simultaneously from the rectum and anus using 4 ring electrodes. The difference in MEP latencies between the transcranial (TMS) and translumbar transsacral magnetic stimulations was calculated as cortico-spinal conduction time. MEP data were compared between patients with FI and controls. Patients filled out questionnaires that assessed the severity and effects of FI., Results: The MEP latencies with TMS were significantly longer in patients with FI than controls at most sites, and on both sides (P < .05). Almost all translumbar and transsacral MEP latencies were significantly prolonged in patients with FI vs controls (P < .01). The cortico-spinal conduction time were similar, on both sides, between patients with FI and controls. Ninety-three percent of patients had 1 or more abnormal translumbar and transsacral latencies, but neuropathy was patchy and variable, and not associated with sex or anal sphincter function or defects., Conclusions: Patients with FI have significant neuropathy that affects the cortico-anorectal and spino-anorectal efferent pathways. The primary loci are the lumbo-rectal, lumbo-anal, sacro-rectal, and sacro-anal nerves; the cortico-spinal segment appears intact. Peripheral spino-anal and spino-rectal neuropathy might therefore contribute to the pathogenesis of FI., (Copyright © 2019 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Introduction and Aims: Fecal incontinence is a disabling condition with devastating consequences for the patients. Medical and surgical options are not very satisfactory, reason by which regenerative medicine has been considered in this field. In the present research, we analyzed functional and histologic effects after implanting pluripotent stem cells (PSCs) in a murine model with sphincterotomy., Materials and Methods: Female Wistar rats were subjected to sphincterotomy and divided into three groups. Group 1 (control group) was treated with 300μL of balanced saline solution and group 2 (late treatment) and group 3 (early treatment) received 50,000 PSCs resuspended in 300μL of balanced saline solution. All animals were evaluated through high-resolution anorectal manometry 24hours before and after sphincterotomy and every month for three months. Finally, the rats were euthanized and histopathologic sections from the anal canal were obtained., Results: All groups showed a decrease in resting anal pressure and squeeze anal pressure 24hours after sphincterotomy. At the third month, higher anal pressures in the groups treated with PSCs were detected. Regarding the histologic effects, the microscopic architecture was restored and there was a significant decrease in the inflammatory response in the groups treated with PSCs., Conclusion: PSCs implantation improves anal tone, as well as histologic structure, presenting better regenerative results when implanted as early treatment., (Copyright © 2018 Asociación Mexicana de Gastroenterología. Publicado por Masson Doyma México S.A. All rights reserved.)

Critically ill patients with fecal incontinence are at high risk of developing incontinence-associated dermatitis (IAD). Scientific prediction and prevention of IAD are essential., Purpose: The purpose of this study was to determine the risk factors for IAD among critically ill patients with fecal incontinence. Based on this information, a predictive risk assessment model was developed to provide research evidence for IAD prevention., Methods: A prospective study was conducted from October 2016 to December 2017. Convenience sampling was used to recruit patients with fecal incontinence treated in intensive care units (ICUs) at Tianjin Medical University General Hospital in China. Trained nurses collected demographic data (age, gender, and ICU type), data related to fecal incontinence (Perineal Assessment Tool [PAT] scores, bowel movement frequency, and stool traits per the Bristol Stool Scale), and clinical data (length of ICU hospitalization, body temperature, diabetes history, hypertension history, consciousness, nutrition support, oxygen supply, number of antibiotic species, sedative use, and albumin levels) from participants and their medical records. The PAT was used to assess patient risk of developing IAD, and the Bristol Stool Scale was used to assess patient stool traits. Names were coded anonymously, and data were entered from paper-and-pencil questionnaires into a software program for statistical analysis. Univariate analysis and multivariate logistic regression were performed to identify risk factors for IAD. A predictive risk factor model was established using a receiver operating characteristic curve., Results: Among 266 critically ill patients with fecal incontinence (182 male, 84 female; mean age 64.18 ± 17.10), IAD incidence was 65.4%. The use of sedative drugs, coma status, higher PAT score, more frequent bowel movements, and loose stool were found to be independent risk factors for IAD (P <.05). The subsequent risk factor predictive model had a sensitivity and specificity of 99.4% and 96.7%, respectively, and the agreement rate was 98.1%., Conclusion: The identified risk factors and subsequent predictive model may contribute to timely identification and quantitative risk assessment of IAD among critically ill patients. Additional quantitative research could provide a scientific basis for the development of specific preventive interventions.

Heroin-related myelopathy is an uncommon but often devastating complication of heroin intake. It is usually reported in individuals exposed to intravenous heroin after a variable drug-free period, leading to acute and complete spinal cord injury with poor long-term outcome. We describe an original case of acute longitudinally extensive transverse myelopathy following single heroin and cocaine intravenous exposure after a long period of abstinence confirmed by toxicological hair and retrospective urine drug analysis. This case could provide new insights in the understanding of this rare neurological complication., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Digital rectal examination (DRE) is part of the physical examination, is also essential for the colorectal surgeon evaluation. A good DRE offers precious information related to the patient's complaints, which will help in decision making. It is simple, quick and minimally invasive. In many centers around the world, the DRE is still the only method to evaluate the anal sphincter prior to patient's management. On the other hand, anorectal manometry (ARM) is the main method for objective functional evaluation of anal sphincter pressures. The discrepancy of DRE depending on the examiner to determine sphincter tonus in comparison to ARM motivated this study., Objective: To compare the DRE performed by proficient and non-experienced examiners to sphincter pressure parameters obtained at ARM, depending on examiners expertise., Methods: Thirty-six consecutive patients with complaints of fecal incontinence or chronic constipation, from the anorectal physiology clinic of the University of São Paulo School of Medicine, were prospectively included. Each patient underwent ARM and DRE performed by two senior colorectal surgeons and one junior colorectal surgeon prior to the ARM. Patient's history was blinded for the examiner's knowledge, also the impressions of each examiner were blinded from the others. For the DRE rest and squeeze pressures were classified by an objective scale (DRE scoring system) that was compared to the parameters of the ARM for the analysis. The results obtained at the ARM were compared to the DRE performed by the seniors and the junior colorectal surgeons., Statistical Analysis: Descriptive analysis was performed for all parameters. For the rest and squeeze pressures the Gamma index was used for the comparison between the DRE and ARM, which varied from 0 to 1. The closer to 1 the better was the agreement., Results: The mean age was 48 years old and 55.5% of patients were female. The agreement of rest anal pressures between the ARM and the DRE performed by the senior proficient examiners was 0.7 (CI 95%; 0.32-1.0), while for the junior non-experienced examiner was 0.52 (CI 95%; 0.09-0.96). The agreement of squeeze pressures was 0.96 (CI 95%; 0.87-1.0) for the seniors and 0.52 (CI 95%; 0.16-0.89) for the junior examiner., Conclusion: More experienced colorectal surgeons used to DRE had a more significant agreement with the ARM, thereafter would have more appropriate therapeutic management to patients with sphincter functional problems. ARM, therefore, persists as an important exam to objectively evaluate the sphincter complex, justifying its utility in the clinical practice.

Background: Scleroderma or progressive systemic sclerosis is characterized by a chronic inflammatory process with proliferation of fibrous connective tissue and excessive deposition of collagen and extracellular matrix in the skin, smooth muscle, and viscera. The smooth muscle most involved in scleroderma is that of the esophagus, and dysphagia is the most commonly reported symptom. However, the internal anal sphincter may also be impaired by degeneration and fibrosis, leading to concomitant anal incontinence in scleroderma patients. These patients may neglect to complain about it, except when actively questioned., Objective: To assess anorectal function and anatomy of female scleroderma patients with symptoms of anal incontinence through Cleveland Clinic Florida Fecal Incontinence Score (CCFIS), anorectal manometry and endoanal ultrasound at the outpatient clinic of colorectal and anal physiology, Clinics Hospital, University of São Paulo Medical School (HC-FMUSP)., Methods: Female scleroderma patients were prospectively assessed and questioned as to symptoms of anal incontinence. The anorectal manometry and endoanal ultrasound results were correlated with clinical data and symptoms., Results: In total, 13 women were evaluated. Their mean age was 55.77 years (±16.14; 27-72 years) and their mean disease duration was 10.23 years (±6.23; 2-23 years). All had symptoms of fecal incontinence ranging from 1 to 15. Seven (53.8%) patients had fecal incontinence score no higher than 7; three (23.1%) between 8 and 13; and three (23.1%) 14 or higher, corresponding to mild, moderate, and severe incontinence, respectively. Ten (76.92%) patients had hypotonia of the internal anal sphincter. Three-dimensional endoanal ultrasound showed tapering associated with muscle atrophy of the internal sphincter in six cases and previous muscle defects in three cases., Conclusion: A functional and anatomical impairment of the sphincter is an important factor to assess in patients with progressive systemic sclerosis and it should not be underestimated.

Background and Study Aims: Constipation and fecal incontinence are common problems in neurologically impaired children. This paper aims to give an overview on bowel problems in cerebral palsy children and to suggest a stepwise treatment approach. A pubmed search was performed looking at studies during the past 20 years investigating bowel problems in neurologically disabled children., Results: The search revealed 15 articles. Prevalence and presentation was the subject of 8 papers, confirming the importance of the problem in these children. The other papers studied the results of different treatment modalities. No significant differences between treatment modalities could be demonstrated due to small studied cohorts. Therefore, no specific treatment strategy is currently available. An experienced based stepwise approach is proposed starting with normalization of fiber intake. The evaluation of the colon transit time could help in deciding whether desimpaction and eventually laxatives including both osmotic (lactulose, macrogol) as well as stimulant laxatives might be indicated. Or, in case of fast transit loperamide or psyllium can be tried. Surgery should be a last resort option., Conclusion: Studies investigating constipation and continence in neurologically impaired children are scarce, making it difficult to choose for the optimal treatment. A stepwise treatment approach is proposed, measuring the colon transit time to guide treatment choices., Competing Interests: The authors declare that they have no conflict of interest., (© Acta Gastro-Enterologica Belgica.)

Background: Faecal incontinence (FI) is a substantial health problem with a prevalence of approximately 8% in community-dwelling populations. Sacral neuromodulation (SNM) is considered the first-line surgical treatment option in adults with FI in whom conservative therapies have failed. The clinical efficacy of SNM has never been rigorously determined in a trial setting and the underlying mechanism of action remains unclear., Methods/design: The design encompasses a multicentre, randomised, double-blind crossover trial and cohort follow-up study. Ninety participants will be randomised to one of two groups (SNM/SHAM or SHAM/SNM) in an allocation ratio of 1:1. The main inclusion criteria will be adults aged 18-75 years meeting Rome III and ICI definitions of FI, who have failed non-surgical treatments to the UK standard, who have a minimum of eight FI episodes in a 4-week screening period, and who are clinically suitable for SNM. The primary objective is to estimate the clinical efficacy of sub-sensory SNM vs. SHAM at 32 weeks based on the primary outcome of frequency of FI episodes using a 4-week paper diary, using mixed Poisson regression analysis on the intention-to-treat principle. The study is powered (0.9) to detect a 30% reduction in frequency of FI episodes between sub-sensory SNM and SHAM stimulation over a 32-week crossover period. Secondary objectives include: measurement of established and new clinical outcomes after 1 year of therapy using new (2017 published) optimised therapy (with standardised SNM-lead placement); validation of new electronic outcome measures (events) and a device to record them, and identification of potential biological effects of SNM on underlying anorectal afferent neuronal pathophysiology (hypothesis: SNM leads to increased frequency of perceived transient anal sphincter relaxations; improved conscious sensation of defaecatory urge and cortical/subcortical changes in afferent responses to anorectal electrical stimulation (main techniques: high-resolution anorectal manometry and magnetoencephalography)., Discussion: This trial will determine clinical effect size for sub-sensory chronic electrical stimulation of the sacral innervation. It will provide experimental evidence of modifiable afferent neurophysiology that may aid future patient selection as well as a basic understanding of the pathophysiology of FI., Trial Registration: International Standard Randomised Controlled Trial Number: ISRCTN98760715 . Registered on 15 September 2017.

Background: Hereditary spastic paraparesis (HSP) is a group of rare genetic disorders affecting the central nervous system. Pure HSP is limited to lower limb spasticity and urinary voiding dysfunction. Complex HSP involves additional neurological features. Beyond the described core symptoms, knowledge about the burden of disease for adults with HSP is limited, particularly regarding gastrointestinal functions, fecal incontinence, and urinary symptoms., Methods: We conducted a cross-sectional self-report survey with 108 adult HSP patients (M age  = 57.7 years, SD = 11.5, range 30 to 81; 54.2% females) recruited from a national HSP user group association and a national (non-clinical) advisory unit for rare disorders. HSP data was compared to data from a Norwegian population study, HUNT-3 (N = 46,293)., Results: The HSP group reported more gastrointestinal and urinary complaints compared to controls. Gastrointestinal complaints included at least "much" complaints with constipation (14.6%) and alternating constipation/diarrhea (8.0%), and at least daily uncontrollable flatulence (47.6%), fecal incontinence (11.6%), and inability to hold back stools (38.5%). Urinary complaints included frequent urination (27.4% > 8 times daily), sudden urge (51.9%) and urinary incontinence (30.5% at least daily/nightly)., Conclusion: This survey of adults with HSP recruited from non-clinical settings showed constipation, alternate constipation and diarrhea, fecal incontinence, and voiding dysfunction represent considerable problems for many persons with HSP. Health care providers should screen and manage often unrecognized gastrointestinal and fecal incontinence complaints among HSP patients.

Purpose: The aim of this study is to analyse colon transit time (CTT) and anorectal manometry (ARM) in children with spina bifida (SB) as a predictor for achieving spontaneous faecal continence., Methods: SB patients (2.5-7 years old) followed at the SB Reference Centre Ghent University Hospital underwent CTT and/or ARM before starting bowel management. A standardized questionnaire about the presence of constipation and faecal incontinence was completed. CTT was measured using a 6-day pellet abdominal X-ray method. ARM was performed in nonsedated children using a latex-free catheter., Results: Twenty-two patients were studied, with a median age of 4.57 years. They all underwent a CTT study, 17 (77%) also agreed to ARM. 10/22 patients (45.5%) were constipated. 5/22 patients (22.7%) became spontaneously continent, 10/22 (45.5%) became pseudocontinent with bowel management, the others remained incontinent. SB patients had a significant prolonged CTT compared to healthy controls. In the group with an abnormal CTT study (12 patients), none of the patients developed faecal continence spontaneously, irrespective of the ARM result. In case of a normal CTT study (10 patients), 7 agreed to ARM. All children with normal resting pressure (4 patients) gained continence spontaneously. The 3 children with abnormal low resting pressure remained incontinent., Conclusions: This prospective study confirms the predictive value of normal CTT and normal resting pressure, in the evolution towards spontaneous faecal continence. If CTT is abnormal, irrespective of the ARM, bowel management will be necessary to obtain pseudo-continence. In these cases, ARM is not a designated examination., Competing Interests: The authors declare that they have no conflict of interest., (© Acta Gastro-Enterologica Belgica.)

Introduction Total colectomy and ileorectal anastomosis can result in significant defecatory frequency and poor bowel function. The aim of this study was to assess whether a laparoscopic approach is associated with any improvement in this regard. Methods A single institution retrospective review was undertaken of patients undergoing elective total colectomy and ileorectal anastomosis between 2000 and 2011. Those undergoing emergency surgery and paediatric surgery were excluded. The primary outcome measure was satisfactory defecatory function after surgery. Results Forty-nine patients (24 male, 25 female) were included in the study. The median age was 48 years (range: 20-83 years). Laparoscopic total colectomy (LTC) was performed in 20 patients and open total colectomy (OTC) in 29 patients. Indications for surgery were slow colonic transit (n=17), colorectal cancer (CRC) (n=17), CRC with hereditary colorectal cancer syndrome (n=8), inflammatory bowel disease (n=4) and diverticular disease (n=3). In the LTC group, 85% had a satisfactory defecatory frequency of 1-6 motions per day compared with 45% in the OTC cohort (p=0.006). There was no statistically significant difference in bowel frequency related to primary pathology (benign vs cancer surgery, p=1.0). Postoperative complications for both groups included relaparotomy (n=3), anastomotic leak (n=2), small bowel obstruction (n=2), postoperative bleeding (n=1) and pneumonia (n=1). Conclusions This study indicates that long-term defecatory function is better following LTC than following OTC and ileorectal anastomosis. The mechanism for this improvement is unclear but it may relate to the underlying reason for surgery or possibly to reduced small bowel handling leading to fewer adhesions after laparoscopic surgery.

Introduction: According to the Wound Ostomy Continence Nursing Society's Continence Committee, the incidence of fecal incontinence (FI) can occur from 18% to 37% in an acute care setting. A stool management system has been designed to manage FI in bedridden patients and has proven to be efficacious in wound management and prevention and infection control, provide safer patient outcomes, and enhance ease of nursing., Objective: This study aims to evaluate the safety and efficacy of an intrarectal device intended to manage fecal incontinence in hospitalized bedridden patients through nonclinical and clinical testings., Materials and Methods: An uncontrolled pilot evaluation in 20 patients was performed as part of a value-based purchasing evaluation at a tertiary hospital in Tucson, Arizona, to assess safety and efficacy in infection control and wound care. The company-provided engineering bench-top studies of insertion and withdrawal forces of the device versus existing intrarectal balloon catheters also were evaluated., Results: The device has broader patient eligibility and potentially allows 3 times more FI patients to be managed safely. It has lower intrarectal pressures compared with indwelling balloon catheters., Conclusions: This study, along with pilot clinical findings, suggests that this technology minimizes the pressure exerted on the rectal wall. There were significantly fewer forces against the anorectal mucosa compared with the cuff-based catheter during insertion, withdrawal, and accidental expulsion.

Background: The treatment of fecal incontinence (FI) depends upon the dominant pathophysiology: impaired sphincter contractility or overflow due to pelvic floor dyssynergia and insufficient rectal emptying. In this study, we aimed to define the manometric and anorectal ultrasound characteristics in FI patients with and without constipation., Methods: We did a retrospective study of 365 anal manometries, performed between October 2012 and July 2015, in patients with FI. Clinical information was obtained from questionnaires. In 220 of these patients an anorectal ultrasound was also available. Key results : A high prevalence of self-reported constipation was seen in the total population of FI patients (66%). This number was lower (31%) when Rome IV criteria were applied. A very high percentage of manometric pelvic floor dyssynergia was seen in the total population with FI (81%). However, patients with FI and constipation did not show pelvic floor dyssynergia more often than patients without constipation. Anal resting pressure, squeeze pressure and anorectal pressure sensitivity were not different when comparing patients without and with constipation. The prevalence of a functional defecation disorder (FDD) in our study population of FI patients was 20%. Wexner score in this subgroup was lower compared with patients without FDD. Anal sphincter defects were more prevalent in women than men, and were associated with diminished sphincter contractility., Conclusion and Inferences: A very high percentage of FI patients showed manometric pelvic floor dyssynergia. The coexistence of fecal incontinence and constipation did not increase this percentage., Key Messages: Constipation is a frequent and underestimated cause of FI. A correct diagnosis has a major impact on treatment. We aimed to characterize the manometric and transrectal ultrasound profile of FI patients with and without signs of coexisting constipation. - A very high percentage of incontinent patients showed pelvic floor dyssynergia, however no significant difference between the group with and the group without constipation was seen. Anal resting pressure, squeeze pressure and anorectal pressure sensitivity did not differ significantly either., (© Acta Gastro-Enterologica Belgica.)

Neural Tube defects are one of the most common congenital disorders, presenting in a paediatric rehabilitation set-up. With its wide spectrum of clinical presentation and possible complications, the condition can significantly impact an individual's functional capacity and quality of life. The condition also affects the family of the child leaving them with a lifelong impairment to cope up with. Through this 16-year-old child, we shed light on the effects of providing rehabilitation, even at a later stage and its benefits. We also get a glimpse of difficulties in availing rehabilitation services in developing countries and the need to reach out many more neglected children like him with good functional abilities., Competing Interests: Competing interests: None., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Aim: To explore the relationship between such a construct and an existing continence score., Methods: A retrospective study of incontinent patients who underwent anal physiology (AP) was performed. AP results and Cleveland Clinic Continence Scores (CCCS) were extracted. An anal physiology score (APS) was developed using maximum resting pressures (MRP), anal canal length (ACL), internal and external sphincter defects and pudendal terminal motor latency. Univariate associations between each variable, APS and CCCS were assessed. Multiple regression analyses were performed., Results: Of 508 (419 women) patients, 311 had both APS and CCCS measured. Average MRP was 51 mmHg (SD 23.2 mmHg) for men and 39 mmHg (19.2 mmHg) for women. Functional ACL was 1.7 cm for men and 0.7 cm for women. Univariate analyses demonstrated significant associations between CCCS and MRP ( P = 0.0002), ACL ( P = 0.0006) and pudendal neuropathy ( P < 0.0001). The association between APS and CCCS was significant ( P < 0.0001) but accounted for only 9.2% of the variability in CCCS. Multiple regression showed that the variables most useful in predicting CCCS were external sphincter defect, pudendal neuropathy and previous pelvic surgery, but only improving the scores predictive ability to 12.5%., Conclusion: This study shows that the ability of AP tests to predict continence scores improves when considered collectively, but that a constructed summation model before and after multiple regression is poor at predicting the variability in continence scores., Competing Interests: Conflict-of-interest statement: None of them has received fees for serving as a speaker, or been a consultant and/or an advisory board member for any organization(s). None has received research funding for this project. None owns stocks and/or shares relevant to this research. None owns any patents

Study Design: Longitudinal study with postal survey., Objectives: To describe changes in the patterns of neurogenic bowel dysfunction and bowel management in a population of people with spinal cord injury (SCI) followed for two decades., Setting: Members of the Danish SCI Association., Methods: In 1996, a validated questionnaire on bowel function was sent to the members of the Danish SCI Association (n=589). The same questionnaire was sent to all the surviving members in 2006 (n=284) and in 2015 (n=178). A total of 109 responded to both the 1996 and 2015 questionnaires., Results: Comparing data from 2015 with those from the exact same participants in 1996, the proportion of respondents needing more than 30 min for each defaecation increased from 21 to 39% (P<0.01), the use of laxatives increased (P<0.05) and the proportion considering themselves very constipated increased from 19 to 31% (P<0.01). In contrast, the proportion suffering from faecal incontinence remained stable at 18% in 1996 and 19% in 2015. During the 19-year period, there had been no significant change in the methods for bowel care, but 22 (20%) had undergone surgery for bowel dysfunction, including 11 (10%) who had some form of stoma., Conclusion: Self-assessed severity of constipation increased but quality of life remained stable in a cohort of people with SCI followed prospectively for 19 years. Methods for bowel care remained surprisingly stable but a large proportion had undergone stoma surgery.

The number of patients with bowel dysfunction due to the treatment of rectal cancer has increased during the recent decades. Anatomical and functional disorders after the removal of the rectum are followed by increased stool frequency, urgency, multiple evacuations and flatus or stool incontinence characterizing the low anterior resection syndrome - LARS. The purpose of this article is to present a review of the literature on current concepts and pathophysiological aspects of bowel dysfunction after resection of rectal cancer. It is essential to understand these mechanisms for a better management of patients and recovery of their quality of life.

Background & Aims: Low estrogen levels can contribute to development of fecal incontinence (FI) in women after menopause by altering neuromuscular continence mechanisms. However, studies have produced conflicting results on the association between menopausal hormone therapy (MHT) and risk of FI., Methods: We studied the association between MHT and risk of FI among 55,828 postmenopausal women (mean age, 73 years) who participated in the Nurses' Health Study, were enrolled since 2008, and with no report of FI. We defined incident FI as a report of at least 1 liquid or solid FI episode per month during 4 years of follow-up from self-administered, biennial questionnaires administered in 2010 and 2012. We used Cox proportional hazard models to calculate multivariate-adjusted hazard ratios and 95% confidence intervals (CIs) for FI risk in women receiving MHT, adjusting for potential confounding factors., Results: During more than 185,000 person-years of follow-up, there were 6834 cases of incident FI. Compared with women who never used MHT, the multivariate hazard ratio for FI was 1.26 (95% CI, 1.18-1.34) for past users of MHT and 1.32 (95% CI, 1.20-1.45) for current users. The risk of FI increased with longer duration of MHT use (P trend ≤ .0001) and decreased with time since discontinuation. There was an increased risk of FI among women receiving MHT that contained a combination of estrogen and progestin (hazard ratio, 1.37; 95% CI, 1.10-1.70) compared with estrogen monotherapy., Conclusions: Current or past use of MHT was associated with a modestly increased risk of FI among postmenopausal women in the Nurses' Health Study. These results support a potential role for exogenous estrogens in the impairment of the fecal continence mechanism., (Copyright © 2017 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Objective: To analyse pelvic floor muscle strength (PFMS) and urinary and anal incontinence (UI and AI) in the postpartum period., Method: Cross-sectional study carried out with women in their first seven months after child birth. Data were collected through interviews, perineometry (Peritron™), and the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF)., Results: 128 women participated in the study. The PFMS mean was 33.1 (SD=16.0) cmH2O and the prevalence of UI and AI was 7.8% and 5.5%, respectively. In the multiple analyses, the variables associated with PFMS were type of birth and cohabitation with a partner. Newborn's weight, previous pregnancy, UI during pregnancy, and sexual activity showed an association with UI after child birth. Only AI prior to pregnancy was associated with AI after childbirth., Conclusion: Vaginal birth predisposes to the reduction of PFMS, and caesarean section had a protective effect to its reduction. The occurrence of UI during pregnancy is a predictor of UI after childbirth, and women with previous pregnancies and newborns with higher weights are more likely to have UI after childbirth.AI prior to pregnancy is the only risk factor for its occurrence after childbirth. Associations between PFMS and cohabitation with a partner, and between UI and sexual activity do not make possible to conclude that these variables are directly associated., Objetivo: Analisar a força dos músculos do assoalho pélvico e a incontinência urinária e anal no período pós-parto., Método: Estudo transversal realizado com mulheres nos primeiros 7 meses após o parto. Os dados foram coletados por meio de entrevista, da perineometria (Peritron™) e do International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF)., Resultados: Participaram do estudo 128 mulheres. A média da força dos músculos do assoalho pélvico foi 33,1 (d.p.=16,0) cmH2O e a prevalência de incontinência urinária e incontinência anal foi de 7,8% e 5,5%, respectivamente. Na análise múltipla, as variáveis associadas à força dos músculos do assoalho pélvico foram tipo de parto atual e coabitação com o parceiro. Peso do recém-nascido, gestação anterior, incontinência urinária na gestação e atividade sexual mostraram associação. Apenas a incontinência anal prévia à gestação associou-se à incontinência anal após o parto., Conclusão: O parto vaginal predispõe à redução da força dos músculos do assoalho pélvico, e a cesariana exerce função protetora à sua redução. A ocorrência de incontinência urinária na gestação é preditora da incontinência urinária após o parto, e as mulheres com gestação anterior e recém-nascido de maior peso têm maior propensão em apresentar incontinência urinária após o parto. Incontinência anal prévia à gestação é o único fator de risco para sua ocorrência após o parto. As associações entre força dos músculos do assoalho pélvico e coabitação com o parceiro e entre incontinência urinária e atividade sexual não permitem concluir que essas variáveis estejam diretamente relacionadas.