Liquid Stool Incontinence Research Articles

Factors affecting continence after fistulotomy for intersphincteric fistula-in-ano

This study was undertaken to determine the incidence of and risk factors for anal incontinence after fistulotomy for intersphincteric fistula-in-ano. We also evaluated the role of anal manometry in preoperative assessment of intersphincteric fistula. A prospective, observational study was undertaken in 148 patients who underwent fistulotomy for intersphincteric fistula between January and December 2004. Functional results were assessed by standard questionnaire and anal manometry. Possible factors predicting postoperative incontinence were examined by univariate and multivariate regression analyses. The mean follow-up period was 12 months. Postoperative anal incontinence occurred in 30 patients (20.3%), i.e., soiling in 6, incontinence for flatus in 27, and incontinence for liquid stool in 4. Fistulotomy significantly decreased maximum resting pressure (85.9 +/- 20.4 to 60.2 +/- 18.4 mmHg, P < 0.0001) and length of the high pressure zone (3.92 +/- 0.69 to 3.82 +/- 0.77 cm, P = 0.035), but it did not affect voluntary contraction pressure (164.7 +/- 85.2 to 160.3 +/- 84.8 mmHg, P = 0.2792). Multivariate analysis showed low voluntary contraction pressure and multiple previous drainage surgeries to be independent risk factors for postoperative incontinence. Fistulotomy produces a satisfactory outcome in terms of eradicating sepsis and preserving function in the vast majority of patients with intersphincteric fistula with intact sphincters. However, sphincter-preserving treatment may be advocated for patients with low preoperative voluntary contraction pressure or those who have undergone multiple drainage surgeries. Preoperative anal manometry is useful in determining the proper surgical procedure.

Prevalence and risk factors for pelvic floor symptoms in women in rural El Salvador

Our aim was to assess the frequency of pelvic floor symptoms among women in rural El Salvador. After written informed consent was obtained, we administered the short form of the urodynamic distress inventory (UDI-6) plus four other pelvic floor questions to 236 women aged 30 to 75 in rural El Salvador attending a general medicine or gynecology clinic. Average (SD) age, parity, and body mass index were 48.0 (8.4) years, 5.9 (3.4), and 26.9 (4.9) kg/m(2), respectively. Ten (4.2%) women had a prior hysterectomy, 16 (6.8%) women were smokers, and 108 (45.8%) women were postmenopausal. Seventy-one percent of women reported urinary incontinence (UI); 49.3 and 61.1% of women reported urge UI and stress UI, respectively. Forty-one percent of women reported fecal incontinence (FI) of solid or liquid stool. Women with UI were significantly more likely to have had a hysterectomy compared to women without UI. Women with FI had significantly fewer years of education when compared to women without FI. In conclusion, pelvic floor symptoms are highly prevalent among women in rural El Salvador.

Low hemorrhoidopexy staple line does not improve results and increases risk for incontinence

The ability of stapled hemorrhoidopexy (SH) to cure hemorrhoidal symptoms appears to depend on patient characteristics and operative technique. We assessed the association between outcome of SH and patients' characteristics and procedure parameters (associated procedure, suture line height, doughnut size, presence of malpighian tissue or smooth muscle in specimen). A total of 68 consecutive patients (56 males) were prospectively operated by 3 different surgeons. Hemorrhoids were grade II (6%), grade III (76%) or grade IV (18%). At a mean 32-week follow-up (range, 9-77), symptoms had resolved in 77% of patients, independently of any operative or clinical parameter. New onset anal incontinence occurred in 11 men (17%): all had urgency, with flatus and liquid stool incontinence in two, and flatus incontinence and mucus soiling in one. Univariate analysis revealed that persistent incontinence was associated with a staple line <6.5 mm from the dentate line, doughnut height <22 mm, and congestive external hemorrhoids; it was also operator dependent (p<0.05). At the 4-week follow-up, 19% of patients had persisting symptoms but only 8% had a demonstrable mucosal prolapse. Although the success rate of SH may not be influenced by technical variations, risk for moderate incontinence is elevated when the stapled line is low.

Categorization of major and minor complications in the treatment of patients with resectable rectal cancer using short‐term pre‐operative radiotherapy and total mesorectal excision: a Delphi round

To properly balance the benefit (reduction of local recurrence) of short-term pre-operative radiotherapy for resectable rectal cancer against its harm (complications), a consensus concerning the severity of complications is required. The aim of this study was to reach consensus regarding major and minor complications after short-term radiotherapy followed by total mesorectal excision in the treatment of rectal carcinoma, using the Delphi technique. A Delphi round was performed in cooperation with 21 colo-rectal surgeons from the Netherlands, United Kingdom and Sweden. The key-question was: 'Which of the predefined complications, caused or substantially aggravated by radiotherapy, are so important (major) that they might lead to the decision to abandon short-term pre-operative radiotherapy (5 x 5Gy) when treating patients with resectable rectal cancer (T1-3N0-2M0)?' After three rounds, consensus was reached for 37 (68%) of 54 complications of which 13 were considered major and 24 considered minor. The following complications were considered to be major: mortality, anastomotic leakage managed by relaparotomy, anastomotic leakage resulting in persisting fistula, postoperative haemorrhage managed by relaparotomy, intra-abdominal abscess without healing tendency, sepsis, pulmonary embolism, myocardial infarction, compartment syndrome of the lower legs, long-term incontinence for solid stool, long-term problems with voiding, pelvic fracture with persisting pain, and neuropathy with persisting pain (legs). Three of 17 complications without consensus showed a tendency to be considered as major: perineal wound dehiscence managed by surgical treatment, small bowel obstruction leading to relaparotomy and long-term incontinence for liquid stool. The 13 major and three 'accepted as major' complications can be used to properly balance the benefit and harm of short-term pre-operative radiotherapy in resectable rectal cancer. This may eventually lead to improved treatment strategies for these patients.

Experience of posterior division of the puborectalis muscle in the management of chronic constipation.

Nine women with severe chronic constipation who were unable to expel a water-filled rectal balloon underwent posterior division of the puborectalis muscle. Pre-operative concentric needle electromyography and measurement of the anorectal angle at rest and during straining suggested that the puborectalis muscle failed to relax during attempted defaecation in these patients. Two patients reported improvement after surgery and had normal balloon expulsion after operation. However seven patients reported no benefit from surgery and tests of defaecatory function and anorectal angle did not change. Incontinence for solid stool was not reported following puborectalis muscle division although five patients reported incontinence of flatus, liquid stool and mucus.

Fistulotomy without external sphincter division for high anal fistulae

Thirty-two patients with high trans-sphincteric or suprasphincteric fistulae underwent fistulotomy without external sphincter division. Fifteen patients had posterior fistulae involving the deep postanal space and 17 patients had anterior fistulae. Primary healing, after removal of the seton, occurred in 25 of the 32 patients (78 per cent). Primary healing in patients with posterior fistulae occurred in 66 per cent and in 88 per cent of patients with anterior fistulae. Following surgery, eight patients (33 per cent) reported problems controlling flatus, six patients (25 per cent) reported mucous discharge and one patient (4 per cent) complained of occasional incontinence for liquid stool. No patient experienced problems controlling solid stool nor did any patient require the use of a protective pad. These results have encouraged us to use this method as the initial procedure of choice for these more difficult fistulae. A significant number of patients can be cured of their fistula while preserving the external sphincter, thereby minimizing the impact of surgical therapy on continence.

Frequency of Persistent Anal Symptoms After First Instrumental Delivery

This study was designed to evaluate persistent anal symptoms after first instrumental delivery beyond the postpartum period. This prospective study was performed in a cohort of primiparas who underwent instrumental delivery from January 1, 2001 to September 30, 2002. Questionnaires for anal symptoms were completed in the maternity ward on the day after delivery and by mail or telephone up to 12 months after the end of the inclusion period. Symptoms of fecal incontinence (solid and/or liquid stool) and precursor symptoms (flatus incontinence, soiling, and/or fecal urgency) were recorded. Of the 212 females who completed the first questionnaire, 159 (75 percent) responded to the second. Overall, 8.8 percent of females had solid and/or liquid stool incontinence, 7.5 percent had involuntary flatus, 8.2 percent had symptoms of fecal urgency, and 24.5 percent experienced new anal symptoms, Of the five females with third-degree tears, none complained of anal incontinence. The only significant difference in delivery data between females who did and did not develop new anal symptoms was larger fetal head size in the new symptom group (96.4 vs. 93.9 mm, respectively; P < 0.05). Frequency of new anal symptoms other than incontinence beyond postpartum period is underestimated in primiparas after instrumental delivery. Only fetal head size was found to predict occurrence of persistent anal incompetence after instrumental delivery.

Anal incontinence in women presenting for gynecologic care: Prevalence, risk factors, and impact upon quality of life

The purpose of this study was to estimate the prevalence and impact upon quality of life of anal incontinence (AI) in women aged 18 to 65. Consecutive women presenting for general gynecologic care were given a bowel function questionnaire. Women with AI were prompted to complete the Fecal Incontinence Severity Index (FISI) and Fecal Incontinence Quality of Life Scale (FIQL). The cohort was composed of 457 women with a mean age of 39.9 +/- 11 years. AI prevalence was 28.4% (95% CI 24.4-32.8). After logistic regression, IBS (OR 3.22, 1.75-5.93), constipation (OR 2.11, 1.22-3.63), age (OR 1.05, 1.03-1.07), and BMI (OR 1.04, 1.01-1.08) remained significant risk factors. The mean FISI score was 20.4 +/- 12.4. Women with only flatal incontinence scored higher, and women with liquid loss scored lower on all 4 scales of the FIQL. AI is prevalent in women seeking benign gynecologic care, and liquid stool incontinence has the greatest impact upon quality of life.

Sacral nerve stimulation for faecal incontinence following a rectosigmoid resection for colorectal cancer

Following recto-sigmoid resection some patients may become faecally incontinent and remain so despite conservative treatment. This multicentre prospective study assessed the use of sacral nerve stimulation (SNS) in this group. All patients had more than or equal to 4 days of faecal incontinence for solid or liquid stools over a 21-day period following recto-sigmoid resection for colorectal carcinoma. The operation had to have been deemed curative. They had to have failed pharmacological and biofeedback treatment. Three male patients met these criteria. One had had a colo-anal and two a colo-rectal anastomosis for rectal carcinoma. All patients had intact internal and external anal sphincters. Two patients had a successful temporary stimulation period and proceeded to permanent implantation. Pre-operative symptom duration was 1 year in the permanently implanted patients. They were followed up for 12 months. SNS improved the number of faecally incontinent episodes in both patients. Ability to defer was improved in both patients from 0--5 min to 5--15 min. The faecal incontinence-specific ASCRS quality of life assessment improved in all four subcategories. This study demonstrates that SNS may be effective in the treatment of patients with faecal incontinence following recto-sigmoid resection if conservative treatment has failed.

Endosonography of the anal sphincter in women of different ages and parity

To obtain reference data representative of normal findings at anal endosonography in pregnant and non-pregnant women. To determine intraobserver and interobserver agreement in the detection of endosonographic anal sphincter defects in asymptomatic women. Twenty-five non-pregnant nulliparous women and 25 non-pregnant parous women (age range, 20-67 years) and 47 pregnant women (age range, 21-39 years) underwent anal manometry and anal endosonography. The endosonographic internal and external sphincter thickness and sphincter length were measured online. Endosonographic sphincter defects were measured and classified offline from videotapes by two independent examiners using an endosonographic defect score ranging from 0 (no defect) to 16 (maximal defect), the score taking into account the location and the longitudinal and circumferential extension of the defect. Endosonographic sphincter thickness and length did not differ between non-pregnant nulliparous and parous women and did not change substantially with age. The anal sphincter was thicker and the anal resting pressure area and manometric sphincter length were greater in pregnant than in non-pregnant women of the same age (20-39 years). There was good intra- and interobserver agreement with regard to detection of endosonographic anal sphincter defects (kappa > or = 0.70). Eighteen (19%) women had endosonographic sphincter defects but in only four (4%; 4/97) cases were they moderate or large (defect score, 7-10). Ten (20%) of the non-pregnant women reported minor gas incontinence and one reported minor incontinence for both gas and liquid stool. The frequency of incontinence did not differ between women with and without sphincter defects. Reference data representative of normal findings at anal endosonography have been established for non-pregnant women and for nulliparous women in the third trimester of pregnancy. Small endosonographic sphincter defects and minor gas incontinence are common in women without known sphincter trauma. They seem to be unrelated to each other and may be regarded as normal variants.

Obstetric anal sphincter injury ten years after: subjective and objective long term effects

To establish the long term effects of obstetric anal sphincter rupture. Prospective observational study. University hospital in Sweden. Eighty-two women from a prospective study from 1990 to compare anorectal function after third degree tear. Women completed a structured questionnaire, underwent a clinical examination and anorectal manometry, endoanal ultrasound (EAUSG) with perineal body measurement. Symptoms of anal incontinence, sexual symptoms, anal manometry scores and evidence of sphincter damage on EAUSG. Five women had undergone secondary repair and three were lost to follow up. Fifty-one women (80%) completed the questionnaire. Twenty-six out of 46 (57%) of the original study group and 6/28 (20%) of the original controls were examined. Incontinence to flatus and liquid stool was more severe in the study group than in controls. Flatus incontinence was significantly more pronounced among women with subsequent vaginal deliveries. Mean maximal anal squeeze pressures were 69 mmHg in the partial rupture group and 42 mmHg in the complete rupture group (P= 0.04). Study group women with signs of internal sphincter injury reported more pronounced faecal incontinence and had lower anal resting pressures (24 mmHg) than those with intact internal sphincters (40 mmHg) (P= 0.01). Perineal body thickness of less than 10 mm was associated with incontinence for flatus and liquid stools, less lubrication during sex and lower anal squeeze pressures (58 mmHg vs 89 mmHg, P= 0.04). Subjective and objective anal function after anal sphincter injury deteriorates further over time and with subsequent vaginal deliveries. Thin perineal body and internal sphincter injury seem to be important for continence and anal pressure.

Paper 44: Anal Sphincter Injury in Women With and Without Pelvic Floor Disorders: A Case-Control Study

OBJECTIVES: A high rate of anal incontinence (AI) and anal sphincter injury (ASI) was previously reported in a cohort of women with pelvic floor disorders.1 The aim of this study was to compare the prevalence of AI and ASI in women with pelvic organ prolapse (POP) and/or urinary incontinence (UI) (cases) versus a group of normal controls. METHODS: Ninety healthy controls (Stage 0 or 1 POP and no UI) and 100 women with pelvic floor disorders (≥ Stage II POP and/or UI) completed the Rockwood-Thompson fecal incontinence severity index questionnaire (FISI). The FISI is a validated severity index whose score (0–61) is generated based on the frequency of incontinence of gas, mucus, liquid, or solid stool. Prolapse was recorded using the ICS's Pelvic Organ Prolapse Quantification system (POP-Q). All women underwent endoanal ultrasonography using a 7-MHz transducer and a 360-degree rotating probe and the internal and external anal sphincters were reported as intact versus disrupted. Chi-square, student t-test, and logistic regression were used for statistical analysis and odds ratios, means, medians and standard deviations were reported as appropriate. RESULTS: Cases differed from controls in the following categories: Mean age (57 versus 53, P=0.05), race (77% versus 58% white, 21% versus 41% black, P=0.02), history of operative vaginal delivery (46% versus 32%, P=0.04) and highest mean infant birth weight (3650 g versus 3470 g, P=0.03). Women with pelvic floor disorders were significantly more likely to report AI (54% versus 18%, OR 5.4, 95% CI 2.8–10,6, P<0.001) and had higher mean FISI scores (22.3 ± 13 versus 12.7 ± 6.3, P=0.006) than controls. Cases also had higher rates of ASI on ultrasound than controls (51% versus 30%, P=0.007). Defects of the internal anal sphincter only, external anal sphincter only, or both were found in 1%, 30%, and 21% of cases versus 3%, 16%, and 11% of controls, respectively. The presence of AI was significantly associated with ASI in women with pelvic floor disorders (OR=38.3, 95% CI 12–120, P<0.001) and controls (OR=5.9, 95% CI 3–11, P=0.002). Operative vaginal delivery was significantly associated with AI in cases (OR 3.6, CI 1.6–8.8, P=0.002) but not controls (OR 1.8, CI 0.6–5.6, P=0.3). A logistic regression model that controlled for age, race, BMI, parity, highest infant birthweight, and history of operative vaginal delivery did not reveal any other risk factors for AI. CONCLUSION: In this study, women with pelvic floor disorders had significantly higher rates of anal incontinence and anatomic anal sphincter injury than a group of healthy controls. A strong correlation existed between anal incontinence and anal sphincter disruption in both groups.

Anal sphincter injury after forceps delivery: myth or reality? A prospective ultrasound study of 93 females.

This study was designed to estimate the prevalence of anal sphincter injury after forceps delivery in a large population of females managed by trained obstetricians in a French hospital and to identify factors predictive for anal sphincter injury. We performed a prospective study of healthy females older than 18 years with no history of anal incontinence, anorectal abnormalities, or anorectal surgery after their first vaginal delivery. All females were interviewed using a standardized questionnaire concerning intestinal transit and continence status. Physical examination and endoanal ultrasonography were performed after delivery. Between November 1999 and November 2000, 93 females were included in the study after their first forceps delivery. Eleven patients (11.8 percent) had a partial defect involving the external sphincter, visible on ultrasonography. One patient (1.1 percent) had a partial defect of external sphincter with complete defect of internal sphincter (sequelae of primary repair of a third-degree perineal tear). Seventeen patients (18.2 percent) had flatus incontinence, and four patients (4.3 percent) had liquid stool incontinence. A high daily number of stools was significantly associated with sphincter defect visible on ultrasonography (P=0.02). The development of anal incontinence was not related to sphincter defect on ultrasonography. There was a strong association between perineal tear and sphincter defect visible on ultrasonography (odds ratio, 4.5 (range, 1.2-16.7)). Anal sphincter injury after forceps delivery was identified in <13 percent of our large population of healthy females. Our study does not confirm previous observations that anal sphincter injury is common after forceps delivery; previously published studies may have overestimated the prevalence of this condition. The only factor with significant predictive value for anal sphincter injury was perineal tear. Anal endosonography should be recommended after obstetric perineal tear.

Fecal Incontinence After High-Risk Delivery

In Brief OBJECTIVE To investigate the prevalence of and factors associated with fecal incontinence and its precursors among high-risk women at 12 months postpartum. METHODS A survey of women in the immediate and later postpartum was conducted. Participants were 568 women at higher risk of anal sphincter damage, namely those who had an instrumental delivery and/or delivered a high birth weight infant (4000 g or more) at tertiary teaching hospitals in Australia. Women participated in a baseline hospital-based interview and a 12-month follow-up telephone interview. The main outcome measures were frank fecal incontinence (solid and/or liquid stool) and precursor symptoms (flatal incontinence, soiling, and/or fecal urgency) at 12 months postpartum. RESULTS Prevalence rates were 2.6% for solid stool incontinence and 4.9% for liquid stool incontinence. Overall, 6.9% women had either one or both of these symptoms of frank fecal incontinence. Prevalence rates were 24.4% for flatal incontinence, 10.9% for soiling, and 14.8% for fecal urgency. Overall, 32.4% women had at least one of these precurser symptoms. Concurrent urinary incontinence and postpartum constipation were significantly associated with both frank fecal incontinence and precursor symptoms. In addition, joint hypermobility and older maternal age were associated with frank fecal incontinence, whereas inability to stop the urine flow and multiparity was associated with precursor symptoms. CONCLUSION The present findings suggest that older and multiparous women, and women with joint hypermobility are at increased risk of postpartum anal incontinence symptoms after a high-risk delivery. Concurrent urinary incontinence, flow-stopping inability, and constipation are also associated with postpartum anal incontinence symptoms after high-risk deliveries. Older and multiparous women, and women with joint hypermobility, constipation, or urinary incontinence are at increased risk of postpartum anal incontinence symptoms after high-risk delivery.

Fecal incontinence after high-risk delivery

Objective To investigate the prevalence of and factors associated with fecal incontinence and its precursors among high-risk women at 12 months postpartum. Methods A survey of women in the immediate and later postpartum was conducted. Participants were 568 women at higher risk of anal sphincter damage, namely those who had an instrumental delivery and/or delivered a high birth weight infant (4000 g or more) at tertiary teaching hospitals in Australia. Women participated in a baseline hospital-based interview and a 12-month follow-up telephone interview. The main outcome measures were frank fecal incontinence (solid and/or liquid stool) and precursor symptoms (flatal incontinence, soiling, and/or fecal urgency) at 12 months postpartum. Results Prevalence rates were 2.6% for solid stool incontinence and 4.9% for liquid stool incontinence. Overall, 6.9% women had either one or both of these symptoms of frank fecal incontinence. Prevalence rates were 24.4% for flatal incontinence, 10.9% for soiling, and 14.8% for fecal urgency. Overall, 32.4% women had at least one of these precurser symptoms. Concurrent urinary incontinence and postpartum constipation were significantly associated with both frank fecal incontinence and precursor symptoms. In addition, joint hypermobility and older maternal age were associated with frank fecal incontinence, whereas inability to stop the urine flow and multiparity was associated with precursor symptoms. Conclusion The present findings suggest that older and multiparous women, and women with joint hypermobility are at increased risk of postpartum anal incontinence symptoms after a high-risk delivery. Concurrent urinary incontinence, flow-stopping inability, and constipation are also associated with postpartum anal incontinence symptoms after high-risk deliveries.

Clinical symptoms after anal sphincter rupture: a retrospective study.

To evaluate the current anal sphincter function, the frequency of urinary incontinence and of dyspareunia in patients with earlier anal sphincter rupture following vaginal delivery. Retrospective case-control study between 1994 and 1999 at the Central Hospital of Helsingborg, Sweden. Two hundred and eighteen women with a history of obstetric anal sphincter rupture and 436 matched controls. Postal questionnaire regarding anal incontinence, urinary incontinence, dyspareunia and lifestyle alterations. Obstetric data were collected from hospital records. Of the 654 women included, 534 (82%) responded at a median follow up of 4 ears. Anal incontinence was significantly more common among patients with sphincter rupture. Sixty-one (33%) reported incontinence of flatus and 39 (21%) incontinence of liquid stools compared with 53 (15%) and 26 (7%) in the control group. Dyspareunia was reported by 26 (14%) patients and 20 (6%) controls. The symptoms of dyspareunia seemed to decrease with time. There was no significant difference in urinary incontinence between the two groups. A third of the women in the case group claimed that their problems with anal incontinence affected their daily lives, but only a few had asked for medical assistance. Anal sphincter rupture is strongly associated with anal incontinence and dyspareunia several years postpartum. The complaints affect the daily lives of these women to a great extent.

Anal plug for faecal incontinence.

Despite the availability of pharmacological, behavioural and surgical treatments for faecal incontinence, many patients remain symptomatic. There are few devices designed specifically to cope with this, and perineal pads are inefficient and unacceptable for many patients. This study aimed to evaluate a new device in patients with intractable faecal incontinence. Two sizes of a purpose-designed anal plug were evaluated in 20 patients with intractable faecal incontinence for solid or liquid stool. Each plug size was tested for 2 weeks, with patients completing a structured questionnaire after each size. The majority [14/20] could not tolerate a plug due to discomfort. Four patients (20%) wished to continue to use a plug on a regular basis after the study, and two others on an occasional basis. However, for this minority who could tolerate a plug, it was highly successful at controlling faecal incontinence. There was no clear preference for the smaller or larger plug. There was no association between comfort in using the plug and anorectal sensitivity as measured by electrophysiological tests. It was not possible to predict which patients would benefit from plug use. The anal plug is effective in controlling faecal incontinence and is well tolerated in a minority of patients. Evaluation quickly reveals whether the patient will find it an effective and acceptable option. This device therefore offers a further management option for patients with faecal incontinence.

The value of posterior levator repair in the treatment of anorectal incontinence due to rectal prolapse--a clinical and manometric study.

When treating a complete rectal prolapse, the most important objective is elimination of the prolapse. In addition, restoration of sufficient anorectal continence is extremely important for the patients. We examined the value of posterior levator repair with respect to stabilization of the pelvic floor and to improvement in anorectal incontinence. In patients with disabling anorectal incontinence, a posterior levatorplasty can be concomitantly performed during operative removal of the prolapse. To facilitate evaluation of the operative results, we implemented a scoring system to judge the patients' subjective symptoms of incontinence; in addition, we performed manometric measurements of resting and squeezing pressures of the anal sphincter to objectify the anorectal incontinence. From 1991 to 1997, 84 patients (mean age 65+/-10 years, 38-91 years; 79 women, 5 men) with complete rectal prolapse and severe incontinence were operatively treated; corresponding follow-ups were done. The following procedures were performed: Frykmann-Goldberg, 28 patients; Wells, 18 patients; Ripstein, 22 patients; and perineal proctectomy, 16 patients. Incontinence for liquid and solid stools was present in all of these patients. Posterior levatorplasty was implemented in 38 patients, and in this group we found significantly better postoperative results, both clinically and in the manometric measurements. Continence was improved by 84% in the group with levatorplasty, but improvement was only 67% in the other group (P<0.05). The incontinence score decreased significantly in the group with levatorplasty (preoperative 16.4+/-3.1, postoperative 9.3+/-4.5, P<0.05, vs the other group with preoperative 15.6+/-4.2, postoperative 11.5+/-5.1). Manometric observations in the group with levatorplasty demonstrated 55% improvement in resting pressure (preoperative 29+/-17 cm H2O, postoperative 45+/-21 cm H2O, P<0.05) and 40% improvement in squeezing pressure (preoperative 61+/-25 cm H2O, postoperative 85+/-31 cm H2O, P<0.05). In the group without levatorplasty, resting and squeezing pressure improved only by 20% (resting pressure: preoperative 32+/-16 cm H2O, postoperative 38+/-18 cm H2O; squeezing pressure: preoperative 64+/-29 cm H2O, postoperative 75+/-26 cm H2O). Posterior levatorplasty is an easy and efficient operative procedure which facilitates an improvement in anorectal continence. There are no apparent disadvantages. For this reason, levatorplasty can be part of operative procedures implemented in the treatment of a complete rectal prolapse accompanied by disabling anorectal incontinence.

V-Y island flaps for repair of large perianal defects

Background: Some perianal diseases such as Paget disease and Bowen disease are extensive and require a wide circumferential excision including the entire anoderm of the anal canal. Methods: We describe a technique of V-Y island flaps to cover the large perianal defects and the denuded anal canal. It is important to excise the base of the flaps in order to fit them into the anal canal. Results: There were 10 women and 5 men with an average age of 54 years (range 32 to 77). The mean follow-up was 45 months (range 6 to 92). The underlying pathology included various kinds of neoplastic and nonneoplastic diseases. There were no major complications such as flap loss or infection. Most complications were minor, including superficial wound separation, flap hematoma, and anal stricture. Although initially all patients had some degree of incontinence for gas and liquid stool or discharge, none of them had significant fecal incontinence at the time of last follow-up. A diverting ileostomy or colostomy was created in 5 patients. Its role was not clear but it did help in the management of the wounds and minimized the pain.

The treatment of fecal incontinence after traumatic vaginal delivery: overlapping sphincteroplasty, internal anal sphincter imbrication, levatorplasty, culdoplasty, and perineorrhaphy

Objective: To assess the operative procedure used in the treatment of fecal incontinence after traumatic vaginal delivery and the functional outcome after surgery. Methods: Between 1995 and 1998, a prospective nonrandomized study was conducted on 22 patients, all of whom had complete fecal incontinence of gaseous, liquid, and solid stool. Preoperatively, all patients were found to have anterior rupture of the external anal sphincter after vaginal deliveries. All patients underwent overlapping sphincteroplasty, culdoplasty, levator ani plication, and perineorrhaphy. Results: Incontinence to gas was found in only one woman (6%). Liquid incontinence was reported in 3 of 22 patients (13.7%). One patient (6%) experienced incontinence to solid stool. A total of four patients (18.2%) suffered constipation, but in only three patients (17%) did the constipation persist after 1 month. Ninety-five percent of the patients had no incontinence to solid stool. The mean follow-up period was 20 months. Conclusion: Ninety-five percent of patients are continent to solid stool. A total of 82% of patients suffer no fecal incontinence and experience excellent functional status, maintaining Grade III and IV continence.