Anterior Sphincteroplasty Research Articles

Клиническое наблюдение редкого варианта аноректальной мальформации – стеноза ануса с передним удвоением прямой кишки

In this article, we report a rare case of anorectal malformation (anal stenosis) in combination with anterior communicating rectal tubular duplication in a 10-month-old boy. The patient presented with constipation, bloating, anal narrowing, and an additional opening in the anterior semicircle of the anal sphincters. His diagnosis was confirmed by contrast-enhanced computed tomography. Surgical treatment was conducted by stages and included colostomy, rectal duplication removal with anterior sphincteroplasty, and stoma closure. One year postoperatively, the child had regular stools, no fecal incontinence, and a good cosmetic result of the operation. We emphasized late diagnosis of this congenital malformation. In case of an additional opening in the anterior semicircle of the anus, it is necessary to exclude colonic duplication using visualization methods. Digital rectal examination is recommended to exclude anal stenosis in such patients. Key words: anorectal malformations, anal fistula, colonic duplication

Long-term results from modified sphincteroplasty in patients with traumatic sphincter injury: a retrospective study.

The results from sphincteroplasty may worsen over time. Reseparation of the rectum and vagina/scrotum in conjunction with sphincteroplasty achieves good results. Improving the surgical effect of sphincteroplasty through perineal body reconstruction is crucial. To evaluate the long-term results from anterior sphincteroplasty and perineal body reconstruction (modified sphincteroplasty) among patients with traumatic sphincter injury. Retrospective study among patients who underwent modified sphincteroplasty in a university hospital between January 2006 and December 2018. Fifty patients were evaluated in detail. The following variables were evaluated: gender, age, additional disease status, time interval between trauma and surgery, surgical technique, duration of hospitalization, follow-up period after surgery, manometric values, electromyography results, magnetic resonance imaging scans, Wexner scores, satisfaction levels with surgery and surgical outcomes. The patients' mean age was 44.6 ± 15.1 years. The median follow-up period was 62 months (range, 12-118). The mean Wexner scores preoperatively, postoperatively in first month (M1S) and at the time of this report (AAS) were 15.5 ± 3.2, 1.9 ± 3.15 and 3.9 ± 5.3, respectively. Although improvements in the patients' mean Wexner scores became impaired over time, the postoperative Wexner scores were still significantly better than the preoperative Wexner scores (P = 0.001). Good or excellent results were obtained surgically among patients with traumatic sphincter injury. Performing perineal body reconstruction in addition to sphincteroplasty can provide better long-term continence. Surgical outcomes were found to be better, especially among patients younger than 50 years of age and among patients who underwent surgery within the first five years after trauma.

Anterior Sphincteroplasty Procedure Should Be Considered in the Treatment of the Rectocele Because of the Incomplete External Anal Sphincteric Rupture Accompaniment

Anterior Sphincteroplasty Procedure Should Be Considered in the Treatment of the Rectocele Because of the Incomplete External Anal Sphincteric Rupture Accompaniment

Anterior sphincteroplasty for fecal incontinence: predicting incontinence relapse.

This study was designed to evaluate the efficiency of anterior sphincteroplasty in preventing fecal incontinence relapsing in 85 female patients. This observational study followed individuals for up to 10years after intervention. Fecal incontinence relapse was analyzed using Generalized Linear Models and Kaplan-Meier tables. Bias due to informative censoring and missing data were assessed. Two postoperative cutoff Wexner scores (4 and 8) were used to classify individuals into continent or incontinent, and their model implications were examined. The hazard of relapsing appeared constant over time. This led to exponential time-to-relapse functions, and a linear increase of cumulative hazard over time. Predicted median relapsing time was 33years, and overall risk 0.09 ± 0.03, when using a cutoff Wexner score of 8 (moderate), and 5years, overall risk 0.45 ± 0.05, when using a cutoff of 4 (mild). There was a potential underestimation in parameters (bias) due to informative censoring, i.e., individual with better prognoses were more likely to drop out before relapsing compared to those with worse prognoses. Thus, true relapsing times may be longer than our current estimates. The predictive model can be used in practice for individual prognosis after intervention, based on preoperative Wexner scores. The effect of anterior sphincteroplasty on fecal incontinence does not seem to deteriorate over time. A consensus Wexner cutoff is necessary to compare data and interventions.

Advances in the Surgical Treatment of Faecal Incontinence

Faecal incontinence is a common condition. Once conservative therapy has failed, surgical management of this problem is required. Over the last decade, neuromodulation has emerged as an effective and safe treatment. The most widely used form of neuromodulation is sacral nerve stimulation. The other less commonly used techniques are posterior tibial nerve stimulation and pudendal nerve stimulation. Anterior sphincteroplasty still has an important role to play in selected cases. If these treatments fail, then other therapies need to be considered. Recent advances in anal sphincter bulking agents and artificial sphincter devices offer some hope for these patients.

Short‐ and long‐term results of secondary anterior sphincteroplasty in 33 patients with obstetric injury

To study short- and long-term improvement in obstetric anal incontinence after secondary overlapping sphincteroplasty and repeat repairs. A prospective analysis based on incontinence scores and patient satisfaction. Department of Gastroenterological Surgery, Oslo University Hospital, a tertiary unit also dealing with sphincter repair. Of 40 obstetric patients operated consecutively from February 1996 to April 2004, 33 (83%) patients with median age of 36 years were eligible for evaluation. Wexner's and St. Mark's incontinence score, clinical examination, anal ultrasonography and manometry, and neurophysiological examination when indicated. Patient satisfaction to treatment was recorded. The patients had anterior overlapping sphincteroplasty. Five had repeat operations, four sphincteroplasty and two post-anal repair. Anal incontinence, patient satisfaction. The 33 patients were examined after median 7 (range 2-62) months and 103 (62-162) months. Median incontinence scores preoperatively and after short- and long-term follow-up were 12 (5-20), 7 (5-20) (p < 0.01) and 9 (0-18) (p < 0.05), respectively. Three patients (9%) had normalized anal incontinence (score ≤1) after short- and long-term follow-up. Corresponding numbers for improved anal incontinence were 22 (67%) and 16 (49%), respectively. Improvement in incontinence scores and patients' satisfaction were concordant. Symptom duration (n = 7), pudendal neuropathy (n = 6), repeat repair (n = 5) and instrument delivery (n = 3) were associated with adverse outcome. Improvement in anal incontinence at short-term follow-up is attenuated at long-term follow-up. Stoma formation, sacral nerve stimulation and neo-sphincter formation must be considered in compliant patients.

Anterior Sphincteroplasty for Fecal Incontinence: Is the Outcome Compromised in Patients With Associated Pelvic Floor Injury?

It has been shown that vaginal delivery may result not only in sphincter defects, but also in pelvic floor injury. However, the influence of this type of injury on the etiology of fecal incontinence and its treatment is unknown. The present study was aimed to assess the prevalence of pelvic floor injury in patients who underwent anterior sphincteroplasty for the treatment of fecal incontinence and to determine the impact of this type of injury on the outcome of this procedure. Women who underwent anterior sphincteroplasty in the past were invited to participate in the present study. With transperineal ultrasound, which has been developed recently, pelvic floor integrity was examined in 70 of 117 patients (60%). Follow-up was obtained from a standardized questionnaire. The median time period between anterior sphincteroplasty and the current assessment was 106 (range, 15-211) months. Pelvic floor injury was diagnosed in 43 patients (61%). Despite the prior sphincteroplasty, an external anal sphincter defect was found in 20 patients (29%). Outcome did not differ, neither between patients with and those without pelvic floor injury, nor between patients with and those without an adequate repair. However, patients with an adequate repair and an intact pelvic floor did have a better outcome than patients with one or both abnormalities. The majority of female patients with incontinence who were eligible for anterior sphincteroplasty have concomitant pelvic floor injury. Based on the present study, it seems unlikely that this type of injury itself has an impact on the outcome of anterior sphincteroplasty.

Long-Term Results after Anterior Sphincteroplasty for Anal Incontinence

To assess the long term incontinence and quality of life (Qol) results after elective anterior sphincteroplasty for anal incontinence. Short and long term follow-up included respectively 28 and 25 of the 29 patients who were operated between 1989 and 1998 in our institution. Qol was assessed with gastro intestinal quality of life index (GIQLI). Incontinence was graded according to Parks score supplied with St Mark's score at long term follow-up. 21 (73%) patients had a history of obstetric sphincter tears. Mean age at operation was 45 years (range 6-77). Median time from operation to short term follow-up was 26 months (mean 38 months, range 2-113) and 84 months (mean 105, range 74-185) to long term follow-up. At short term follow-up 19 of 28 patients (68%) were continent for stool compared with nine of 25 patients (36%) at long term follow-up. Nine of 17 (53%) who were continent for stool at short term follow-up remained continent for stool at long term follow-up. Patients with a history of obstetric sphincter tear had less severe incontinence at long term follow-up compared to women with other causes of incontinence (St. Mark's score 8 and 16 respectively, p = 0,015). Patients with no incontinence or gas incontinence only, had higher quality of life score at both follow-ups than those who where incontinent for stool (p = 0,007 and p= 0,014 respectively). More than half of the patients remained continent for stool at long term follow-up. Continence for stool was associated with high Qol score.

Anterior Sphincteroplasty for Fecal Incontinence: A Single Center Experience in the Era of Sacral Neuromodulation

Anterior sphincteroplasty is the surgical treatment of choice for patients with fecal incontinence associated with an external anal sphincter defect. Recently it has been reported that patients with such a defect may also benefit from sacral neuromodulation. The success of this technique raises the question whether anterior sphincteroplasty still deserves a place in the surgical treatment of fecal incontinence. This study investigated the outcome of anterior sphincteroplasty in a large cohort of patients. A consecutive series of 172 patients underwent anterior overlapping sphincteroplasty. A standardized questionnaire concerning current continence status, overall satisfaction, and quality of life was used to assess the outcome. Follow-up data were obtained from 75% of the 160 patients who were still alive at the time of the survey. After a median follow-up of 111 (range, 12-207) months, the outcome was still good to excellent in 44 patients (37%). In 28 patients (23%), the outcome was classified as moderate because these patients still experienced regular incontinence for stool. However, they were satisfied with their outcome because their incontinence episodes had been reduced by 50% or more. The outcome was poor in 40% of the patients. Predictors of worse outcome were older age (> or =50 years) at surgery, deep wound infection, and isolated external anal sphincter defects. Patients with follow-up of five or more years had the same outcome as patients with follow-up of fewer than five years. Anterior sphincteroplasty results in an acceptable to excellent long-term outcome in 60% of patients, especially in those under the age of 50 years at surgery.

Anterior sphincter plication and levatorplasty in the treatment of faecal incontinence

The surgical treatment of faecal incontinence has been traditionally divided into sphincteroplasty for sphincter disruption and postanal repair for idiopathic cases. However, many studies have failed to show a correlation between outcome and change in the anorectal angle. This study was carried out to determine the effectiveness of anterior sphincteroplasty and levatorplasty in the treatment of faecal incontinence, regardless of aetiology. Thirty consecutive patients underwent surgery, 14 with traumatic sphincter injuries and 16 with idiopathic faecal incontinence. A satisfactory clinical result was obtained in ten (71 per cent) patients in the traumatic group and in ten (62 per cent) in the idiopathic group. This was associated with a significant increase in maximum voluntary contraction pressure in the traumatic group and in those patients who had a good result in the idiopathic group (traumatic: preoperative median 80 cmH2O (range 50-115 cmH2O) versus postoperative 115 cmH2O (75-290 cmH2O), P less than 0.005; idiopathic: preoperative 105 cmH2O (45-190 cmH2O) versus postoperative 120 cmH2O (45-230 cmH2O), P less than 0.05; Wilcoxon paired signed ranks test). There was also significant improvement in anal sensation in the upper anal canal in both groups (traumatic: preoperative mean 17 mA versus postoperative 11 mA, P less than 0.05; idiopathic: preoperative 24 mA versus postoperative 9 mA, P less than 0.02). The anorectal angle increased in the idiopathic group at rest (preoperative median 105 degrees (range 86-152 degrees) versus postoperative 118 degrees (95-180 degrees), P less than 0.05). In conclusion, the type of approach (anterior or posterior) and the anorectal angle are irrelevant to the outcome of surgery for idiopathic faecal incontinence. Success appears to be related more to improved sphincter pressure and anal sensation.

Physiological and clinical outcome of anterior sphincteroplasty.

A total of 55 women underwent sphincteroplasty for the treatment of faecal incontinence related to anterior defects. Patients were followed prospectively for a mean of 29 months to evaluate the outcome overall and according to age. All patients were evaluated clinically by means of a questionnaire and graded using an incontinence scoring system ranging from 0 (perfect continence) to 20 (complete incontinence). Some 52 patients (95 per cent) had had a previous vaginal delivery and 30 (55 per cent) had a history of previous anal sphincter repair. Physiological and functional parameters in patients with a successful outcome (n = 39) were compared with those in patients with a poor outcome (n = 16). The results were also compared in patients under (n = 39) and over (n = 16) 60 years of age. Overall, patients with a successful outcome had a significant change in mean and maximal resting and squeeze pressures. These changes correlated well with the increase in the high-pressure zone (HPZ) length from 1.0-2.2 cm (P = 0.0002) and with functional outcome (change in incontinence score from 15.3 to 5.8; P < 0.0001). In patients over 60 years of age, a significant change in mean squeeze pressure (P = 0.03) and HPZ length (P = 0.01) was noted and correlated with functional outcome (change in incontinence score from 14.3 to 6.4; P < 0.0001). A successful outcome after anterior sphincteroplasty is related to improvement in sphincter function even in an older population. These results demonstrate that age itself does not seem to be a predictor of poor outcome. Patients should not be denied a repair exclusively on grounds of age.

Is there a role for concomitant pelvic floor repair in patients with sphincter defects in the treatment of fecal incontinence?

More than half of all patients who undergo overlapping anal sphincter repair for fecal incontinence develop recurrent symptoms. Many have associated pelvic floor disorders that are not surgically addressed during sphincter repair. We evaluate the outcomes of combined overlapping anal sphincteroplasty and pelvic floor repair (PFR) vs. anterior sphincteroplasty alone in patients with concomitant sphincter and pelvic floor defects. We reviewed all patients with concomitant defects who underwent surgery between February 1998 and August 2001. Patients were assessed preoperatively by anorectal manometry, pudendal nerve terminal motor latency, and endoanal ultrasound. The degree of continence was assessed both preoperatively and postoperatively using the Cleveland Clinic Florida fecal incontinence score. Postoperative success was defined as a score of <or=5, whereas postoperative quality of life was assessed by a standardized questionnaire. Twenty-eight patients (mean age 52.3 years) underwent overlapping anal sphincteroplasty. The mean follow-up was 33.8 months. Cleveland Clinic Florida scores postoperatively showed a significant improvement from preoperative values (14.2 vs 5.1, p<0.001). Seventeen patients (61%) underwent concomitant PFR with sphincteroplasty. Three patients (27%) without PFR and one patient (6%) with PFR underwent repeat sphincter repair due to worsening symptoms (p=0.15). Two patients with PFR and one patient without PFR ultimately had an ostomy due to a failed repair (p=0.66). Comparing patients with and without PFR, there was a trend toward higher success rates (71 vs. 45%) when pelvic prolapse issues were addressed during sphincter repair. Concomitant evaluation and repair of pelvic floor prolapse may be a clinically significant component of a successful anal sphincteroplasty for fecal incontinence but warrant further prospective evaluation.

Outcome of overlapping anal sphincter repair after 3 months and after a mean of 80 months

The aim of this study was to determine the functional results of anal sphincter repair after a long follow-up (mean 80.1 months). In the period 1990-2002, 65 sphincter repairs were performed. Obstetric trauma was the cause of incontinence in 72.3% cases, fistulotomy in 13.8%, nonspecific trauma in 9.2%, and war injury in 4.6%. At the time of surgery, 12 patients had undergone an urgent stoma procedure. In all cases, anal manometry, electromyography, and defecography were performed. The severity of incontinence was evaluated preoperatively using the Wexner score system. Anterior sphincteroplasty was performed in 52 cases, lateral in 9 cases, and posterior in 4 cases. The results were determined according to the Wexner score system and the Browning-Parks scale. The Wexner score was calculated 3 months after operation and during every follow-up visit. Preoperative scores and those at the first and last follow-up visits were analyzed. Three months after operation excellent results were achieved in 55.5%, good in 18.5%, fair in 16.9%, and poor in 9.2% patients. After follow-up (mean 80.1 months), 26.8% had excellent results, 21.4% had good results, 12.5% had fair results, and 39.3% of patients had a poor outcome. Results determined by the Wexner score system improved from 17.8 preoperatively to 3.6 three months after operation, but deteriorated over time to 6.3 after longer follow-up (p<0.001). Overlapping sphincter repair provides satisfactory results in more than two-thirds of patients initially, but the results tend to worsen over time and are satisfactory in half of patients after longer follow-up.

Ten-Year Outcome of Anterior Sphincteroplasty for Fecal Incontinence

Anterior sphincteroplasty is the most common operation for fecal incontinence in women, but 3- to 5-year results are suboptimal. This report is the

Overlapping sphincteroplasty: does preservation of the scar influence immediate outcome?

BACKGROUND: The importance of the overlapping scar in an anterior sphincteroplasty is often emphasized. The aim of this study was to identify the tissue type used in overlapping sphincter repair based upon ultrasound images, and to correlate these results with the immediate clinical outcome. METHODS: Data were collected prospectively on all patients with faecal incontinence who underwent anterior overlapping sphincteroplasty between June 1998 and May 1999. Continence was assessed by a standardized incontinence score ranging from 0 to 20. Pre-operative ultrasound images were compared to intraoperative ultrasound findings for each patient. In each case the surgeon performed an overlap of what was grossly felt to represent scar after which a single blinded observer performed intraoperative ultrasound. The degree of overlap was measured and classified as hyperechoic over hyperechoic (muscle over muscle; Type 1), hyperechoic over or under hypoechoic (muscle over or under scar; Type 2), hypoechoic over hypoechoic (scar over scar; Type 3). The patient follow-up included incontinence score that was obtained by telephone interview; suboptimal outcome was considered as an incontinence score >/= 6. Statistical analysis was performed using the Mann-Whitney test and Wilcoxon matched-pairs test. RESULTS: Fourteen female patients with a mean age of 51.6 (range 28-79) years were evaluated. The mean pre-operative incontinence score was 17.1 (range 7-20) and 13 of the 14 (93%) patients had an incontinence score >/= 15. All pre-operative ultrasound images were hypoechoic which correlated with the surgeon's intraoperative findings of scar. The operative appearance included two Type 1, four Type 2, and eight Type 3 images. Larger pre-operative ultrasound image defects were statistically significantly related to intraoperative Type 3 ultrasound images. At a mean follow up of 7.5 (range 2-16) months the mean postoperative incontinence score was 4.5 (range 0-12). In patients with Type 1 and Type 2 images, the mean postoperative score was 8.6 (range 4-12) whereas in patients with Type 3 it was 1.3 (range 0-5) (P < 0.003); 7 of the 8 patients in Type 3 (87.5%) had an incontinence score </= 2. CONCLUSION: These preliminary results show a significant immediate benefit to the overlap of scar over scar, however, such overlapping may not always be achieved despite the surgeon's intent. Furthermore, larger pre-operative defects may predispose to more extensive anterior scarring and thus a better chance of achieving this desired overlap.

Clinical rather than laboratory assessment predicts continence after anterior sphincteroplasty.

Preoperative anorectal physiology studies have become part of the standard evaluation of fecal incontinence. This study was undertaken to see whether anorectal physiology results predicted surgical outcome after anterior sphincteroplasty. Between 1985 and 1994, 191 females with a mean age of 37 (range, 20-74) years underwent anterior sphincteroplasty for anal sphincter disruption. A follow-up questionnaire was sent to all patients, and there were 158 respondents (83 percent). Mean follow-up was 43 (range, 6-120) months. Obstetric injuries accounted for incontinence in 91 percent of the 158 patients who responded to the questionnaire. Mean duration of incontinence was 4.2 years (range, 3 months-51 years) before surgery. Preoperatively, patients were incontinent to solid stool (53 percent), liquid stool (33 percent), gas (3 percent), and unspecified (11 percent). Subjectively, the results were as follows: 129 patients (82 percent) improved, 17 (11 percent) were initially improved but subsequently deteriorated, 7 (4 percent) were unchanged, and 5 (3 percent) were worse. Objectively, postoperative continence was classified as follows: excellent (normal) in 23 percent, good (incontinent to gas or minor stain) in 39 percent, fair (incontinent to stool an average of less than once per month) in 26 percent, and poor (incontinent to stool an average of greater than once per month) in 12 percent. Preoperative continence level (incontinent to solid vs. liquid stool) was predictive of postoperative continence classification. Preoperative anorectal manometry was not predictive of clinical outcome (n = 128). There was no significant difference in postoperative continence classification among patients with normal, unilaterally abnormal, and bilaterally abnormal pudendal latency (n = 89). Clinical rather than manometric assessment predicts continence after anterior sphincteroplasty.

Relationship between sphincter morphology on endoanal MRI and histopathological aspects of the external anal sphincter.

Atrophy of the external anal sphincter can be shown only on endoanal magnetic resonance imaging (MRI). Until now no study has compared the morphological endoanal MRI findings with histopathological aspects of the external anal sphincter. The aim of this study was to validate the MRI interpretation of the external anal sphincter using histology as a "gold standard." In this prospective study 25 consecutive unselected women (median age 48 years, range 27-72) with fecal incontinence due to obstetric trauma were assessed preoperatively with endoanal MRI. All patients underwent anterior sphincteroplasty within 6 months of the preoperative assessment. During sphincter repair, a biopsy specimen was taken both from the left and right lateral parts of the external anal sphincter. Interpretation of MRI was performed by one of the radiologists (J.S.), and biopsy specimens were evaluated by the pathologist (W.J.M.). Both were blinded to the interpretation of the other. MRI revealed external anal sphincter atrophy in 9 of the 25 patients (36%). Histopathological investigation confirmed these findings in all but one. In one additional patient atrophy was detected on histological investigation while the morphology of the external anal sphincter was classified as normal on MRI. In detecting sphincter atrophy endoanal MRI showed 89% sensitivity, 94% specificity, 89% positive predictive value, and 94% negative predictive value. MRI correctly identified sphincter morphology in 23 of 25 cases (92%). This study demonstrates that endoanal MRI accurately identifies normal and abnormal external anal sphincter morphology. Endoanal MRI is therefore a valuable preoperative diagnostic tool.

Transvaginal sonography of the anal sphincter: reliable, or not?

The purpose of this study was to validate the use of transvaginal sonography for anal sphincter evaluation, compare this technique with the more commonly used transanal technique, and explain a publication that suggested that transvaginal sonography is unreliable. The study population consisted of 50 women, of whom 44 prospectively underwent transanal and transvaginal sonography. The six remaining patients with surgical confirmation underwent only transvaginal sonography. All images were interpreted by the examining radiologist and then reviewed by a second radiologist who was unaware of the first radiologist's interpretations. Defects in the external and internal anal sphincters, the status of the perineal body, and any perianal collections or fistulas were documented. Twenty-five of the 50 patients showed sphincteric defects. Twenty-two had a defect in the external anal sphincter, of whom 16 had a matching internal anal sphincter defect. Four patients had an isolated internal anal sphincter defect. Surgery in nine of these 22 patients confirmed the defects seen on sonography. The 10th patient who underwent surgery had scar tissue rather than a tear in the external anal sphincter that corresponded with the defect seen on sonography. Defects were identified in all patients presenting with fecal incontinence who had undergone either a primary repair or an anterior sphincteroplasty. Of the 25 patients with intact sphincters on both transvaginal and transanal sonography, four had other significant findings including two perianal abscesses and two T3 rectal carcinomas. In 40 of the 44 patients who were prospectively imaged using both techniques, the sonographic findings were in agreement. Review, performed by a second radiologist who was unaware of the first radiologist's interpretations, verified the findings resulting in an 88.6% interobserver agreement. In all patients, perineal body assessment and assessment of perianal inflammatory disease was more accurate with the transvaginal technique. Transvaginal sonography is a reliable method for evaluating the anal sphincter, with an accuracy equivalent to that of the transanal technique. Transvaginal sonography is preferable for evaluation of the perineal body and perianal inflammatory processes.

Etiology and management of fecal incontinence

Fecal incontinence is a challenging condition of diverse etiology and devastating psychosocial impact. Multiple mechanisms may be involved in its pathophysiology, such as altered stool consistency and delivery of contents to the rectum, abnormal rectal capacity or compliance, decreased anorectal sensation, and pelvic floor or anal sphincter dysfunction. A detailed clinical history and physical examination are essential. Anorectal manometry, pudendal nerve latency studies, and electromyography are part of the standard primary evaluation. The evaluation of idiopathic fecal incontinence may require tests such as cinedefecography, spinal latencies, and anal mucosal electrosensitivity. These tests permit both objective assessment and focused therapy. Appropriate treatment options include biofeedback and sphincteroplasty. Biofeedback has resulted in 90 percent reduction in episodes of incontinence in over 60 percent of patients. Overlapping anterior sphincteroplasty has been associated with good to excellent results in 70 to 90 percent of patients. The common denominator between the medical and surgical treatment groups is the necessity of pretreatment physiologic assessment. It is the results of these tests that permit optimal therapeutic assignment. For example, pudendal nerve terminal motor latencies (PNTML) are the most important predictor factor of functional outcome. However, even the most experienced examiner's digit cannot assess PNTML. In the absence of pudendal neuropathy, sphincteroplasty is an excellent option. If neuropathy exists, however, then postanal or total pelvic floor repair remain viable surgical options for the treatment of idiopathic fecal incontinence. In the absence of an adequate sphincter muscle, encirclement procedures using synthetic materials or muscle transfer techniques might be considered. Implantation of a stimulating electrode into the gracilis neosphincter and artificial sphincter implantation are other valid alternatives. The final therapeutic option is fecal diversion. This article reviews the current status of the etiology and incidence of incontinence as well as the evaluation and treatment of this disabling condition.

Comparison of anterior sphincteroplasty and postanal repair in the treatment of idiopathic fecal incontinence

Both postanal repair and anterior sphincteroplasty with levatorplasty have been advocated in the treatment of idiopathic fecal incontinence. To assess the functional results of these procedures, physiologic and radiologic measurements were carried out prospectively in 33 patients with idiopathic incontinence undergoing operative treatment, and 12 age- and sex-matched controls. Sixteen patients had anterior sphincteroplasty and levatorplasty and 17 had postanal repair. A satisfactory postoperative outcome was defined as perfect continence or incontinence of flatus only. Ten patients in the anterior sphincteroplasty group had satisfactory results (64 percent) and 10 in the postanal repair group (59 percent). Preoperatively, both groups had decreased resting and squeeze pressures, impaired and mucosal electrosensitivity, and marked pelvic descent vs. controls. Postoperatively, significant improvement in sphincter pressures and mucosal electrosensitivity was seen in both groups. No significant change in anorectal angle was demonstrated in the postanal repair group, whereas it was made significantly more obtuse in the anterior sphincteroplasty group. It is likely that the improved continence resulting from either of these two procedures is secondary to better anal sphincter muscle function and improved and sensation. It would appear that the anorectal angle is not crucial in maintaining continence.