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Fecal incontinence is an unvoiced and stressful symptom that recognizes multiple etiologies. Some examples need to be treated medically by measures aimed at reducing stool frequency and improving stool consistency and that can be reinforced by biofeedback directed to improving motor and/or sensory functions. Biofeedback is a safe procedure and represents the first-line conservative therapy following failure of medical or supportive aid in fecal incontinence patients. Future placebo-controlled randomized studies are needed to better evaluate pelvic floor retraining in nonresponders to advice/education only and sensory retraining in incontinent patients. Outcomes should include standardized measures, validated quality of life questionnaires, and long-term assessment of therapeutic success. [ABSTRACT FROM AUTHOR]

SNM can be considered as an effective therapeutic approach to treat patients suffering from FI associated with some kind of neuropathy as the primary or secondary cause. A large number of reports demonstrate the effectiveness of this therapy in improving the FI and patients' quality of life. In all series, episodes of FI are reported to be significantly decreased and FI scores are improved. Urgency is frequently reduced, and altered rectal sensations, compared with those reported by patients preoperatively, are significantly ameliorated in most cases. Also, improvement of almost all variables measuring quality of life represents one of the most important results obtained by SNM application in this group of patients with severe psychological, social, and behavioral problems due to FI. However, the mechanisms of action of SNM are still not well understood. SNM seems to play a multiple role, combining a variety of effects on anal sphincters and rectal sensation and motility via a modulated stimulation of the different nerve pathways involved in defecation physiology, including afferent and efferent connections with the central nervous system. A better understanding of action mechanisms will allow assessment of which clinical conditions are appropriate candidates for SNM. However, the actual evaluation with clinical and instrumental assessment of FI, together with the PNE test, gives the best approach to selecting patients for definitive implantation of an SNM device. In most cases, clinical results observed during the PNE test are reproducible, long-term durable, and not susceptible to the placebo effect. [ABSTRACT FROM AUTHOR]

Dynamic pelvic MRI using either closed-configuration or open-configuration MR systems is a rapidly evolving technique that is considered an alternative to conventional evacuation proctography. In patients with outlet obstruction, the technique may reveal various findings associated with outlet obstruction. [ABSTRACT FROM AUTHOR]

Evacuation proctography or defecography is a long-established and relatively straightforward diagnostic procedure for the investigation of those with symptoms of rectal outlet obstruction. Controversy exists as to the interpretation and clinical utility of the technique largely due to absent or imperfect reference standards for comparison. However, when interpreted sensibly, proctography still has a very important role in patient management, particularly in therapeutic triage. A simplistic (but effective) interpretative approach is to firstly assess the speed and completeness of evacuation (abnormality of which largely suggests an underlying functional problem) and then to describe any structural problems, documenting whether they are likely primary or secondary. [ABSTRACT FROM AUTHOR]

Anal endosonography and MRI are both excellent techniques in imaging perianal fistulas. In anal endosonography, enhancement with HPUS improves diagnostic yield; however, an external fistula opening has to be present. Three-dimensional EAUS will possibly also increase visibility. With MRI, an endoanal coil probably has advantages although several enhancement techniques with a body coil are also very accurate. EAUS can be used in cases where MRI is not possible, such as claustrophobia, extreme obesity, and metallic implants. Also, EAUS is less expensive than MRI. [ABSTRACT FROM AUTHOR]

In the author's opinion, if imaging has to be restricted to one test, then MRI is the clear favorite. However, as stated already, AES and MRI may provide complementary information, and no harm comes from performing both. AES does have some clear advantages although these are related to the fact that it is relatively cheap and simple to perform rather than its technical performance. It is rapid and well tolerated by patients and, unlike MRI, can be performed easily in the outpatient clinic or even on the ward since machines are easily portable. It should also be borne in mind that AES is vastly superior to digital examination in the clinic and is therefore well worth performing, especially if MRI is unavailable or if there is no specific expertise in its interpretation. Also, a major role of AES in fistula disease is to assess the degree of sphincter disruption in those patients who become anally incontinent following surgery. [ABSTRACT FROM AUTHOR]

MRI is becoming important in the management of rectal cancer patients. Knowledge of relevant MR anatomy of the rectum and mesorectum is mandatory for radiologists, surgeons, and radiation oncologists involved in the multidisciplinary approach of rectal cancer. This chapter aimed at providing detailed information on the MR anatomy of clinically relevant structures. [ABSTRACT FROM AUTHOR]

Most anal sepsis can be managed without further imaging. Treatment of recurrent disease and sepsis with an unusual presentation may be augmented with further imaging. This also includes complex perianal Crohn's disease and supralevator sepsis. Exactly which imaging modality is preferable remains unclear in the current literature. Focused studies with the clear endpoint of sepsis that has healed/been eradicated, along with clear study designs free from bias, are needed. Also, current imaging technology must be fairly matched (i.e., modern MRI, 3-D endosonography, etc.) in order to obtain an impartial comparison. [ABSTRACT FROM AUTHOR]