Neurogenic Fecal Incontinence Research Articles

Management of patients with faecal incontinence.

Faecal incontinence, defined as the involuntary loss of solid or liquid stool, is a common problem affecting 0.8-8.3% of the adult population. Individuals suffering from faecal incontinence often live a restricted life with reduced quality of life. The present paper is a clinically oriented review of the pathophysiology, evaluation and treatment of faecal incontinence. First-line therapy should be conservative and usually include dietary adjustments, fibre supplement, constipating agents or mini enemas. Biofeedback therapy to improve external anal sphincter function can be offered but the evidence for long-term effect is poor. There is good evidence that colonic irrigation can reduce symptoms and improve quality of life, especially in patients with neurogenic faecal incontinence. Surgical interventions should only be considered if conservative measures fail. Sacral nerve stimulation is a minimally invasive procedure with high rate of success. Advanced surgical procedures should be restricted to highly selected patients and only performed at specialist centres. A stoma should be considered if other treatment modalities fail.

Treatment fecal incontinence in children with bulking agents «DAM+»

One of the reason of organic and neurogenic fecal incontinence in children is low resting pressure in the anal canal. In functional aspect, one of the main roles plays internal sphincter of the anal canal that provides 50-85 % of basal resting pressure and close of the anal canal. Purposes. The purpose of this article is to study the possibilities of using bulking agent «DAM+» to increase resting pressure in the anal canal in children with fecal incontinence, and evaluate the results of this treatment. Metods. The study has been performed in the Department of Pediatric Surgery in our university since 2007 for 2013. In total, 35 patients, aged 2-18 with organic or neurogenic fecal incontinence were underwent 57 procedure of introduction polyacrylamid gel «DAM+». Patients with overflow fecal incontinence were excluded. Before treatment and after, all patients were assessed clinical examination and anal manometry. Anal manometry was perfomed оn multifunctional apparatus «Menfis 2000». Results. The average quantity of resting pressure in the anal canal before operation is formed 20.98 ± 5.17 сm. (H2O), after operation 32.62 ± 6.63 сm. (H2O), in long-term period 28.07 ± 6.65 сm. (H2O) Conclusion. The clinical efficiency of procedure correlates with values of resting pressure in the anal canal before and after treatment. Implantation of «DAM+» into submucosal layer provides increasing of basal resting tone in the anal canal. Imitation of work of the internal anal sphincter and expansive vascular anal cushions on the other part, prevents patulous anus and provides a hermetic seal, that responds for close anal walls. Statistical data was shown, that the average quantity of resting pressure in the anal canal before operation and after operation has performed at the 5 % significance level. P-values < 0.05 was considered statistically significant.

Low‐resolution colonic manometry leads to a gross misinterpretation of the frequency and polarity of propagating sequences: Initial results from fiber‐optic high‐resolution manometry studies

High-resolution manometry catheters are now being used to record colonic motility. The aim of this study was to determine the influence of pressure sensor spacing on our ability to identify colonic propagating sequences (PS). Fiber-optic catheters containing 72-90 sensors spaced at 1cm intervals were placed colonoscopically to the cecum in 11 patients with proven slow transit constipation, 11 patients with neurogenic fecal incontinence and nine healthy subjects. A 2h section of trace from each subject was analyzed. Using the 1cm spaced data as the gold standard, each data set was then sub-sampled, by dropping channels from the data set to simulate sensor spacing of 10, 7, 5, 3, and 2cm. In blinded fashion, antegrade and retrograde PS were quantified at each test sensor spacing. The data were compared to the PSs identified in the corresponding gold standard data set. In all subject groups as sensor spacing increased; (i) the frequency of identified antegrade and retrograde PSs decreased (P<0.0001); (ii) the ratio of antegrade to retrograde PSs increased (P<0.0001); and (iii) the number of incorrectly labeled PSs increased (P<0.003). Doubling the sensor spacing from 1 to 2cm nearly halves the number of PSs detected. Tripling the sensor spacing from 1 to 3cm resulted in a 30% chance of incorrectly labeling PSs. Closely spaced pressure recording sites (<2cm) are mandatory to avoid gross misrepresentation of the frequency, morphology, and directionality of colonic propagating sequences.

Tu2068 Spatial Aliasing of Colonic Manometry Data: What Have We Been Missing or Mislabeling?

While colonic manometry has helped to defined dysmotility in patients with functional colonic or anorectal disorders, identification of specific manometric markers that assist in subtyping these disorders remains elusive. Typically colonic manometry is recorded with sensor spacing ≥10cm, however we have shown that colonic propagated sequences (PS) can extend over segments as short as 3-5cm(1). It is likely, therefore that traditional manometry is overlooking potentially relevant motor patterns. Aim: To determine the influence of pressure sensor spacing on our ability to accurately identify colonic motility patterns. Method: A fibre-optic catheter containing 72-90 sensors spaced at 1cm intervals was placed colonoscopically to the caecum in 11 patients with scintigraphically confirmed slow transit constipation. Controls comprised 11 patients with neurogenic fecal incontinence and 9 healthy subjects. From each of these recordings a 2hr section of trace was selected to assess motor response to either the response to a 1000kCal meal (healthy controls) or the colonic response to sacral nerve stimulation (patient population). Each data set was analysed in 6 different ways by sub-sampling different sets of the full array to simulate inter-recording site distances of 10, 7, 5, 3, 2 and 1cm. In blinded fashion, in each manometric trace antegrade and retrograde propagating sequences (PS) were identified. Against the 1cm spaced data (gold standard), we compared all the PSs identified at each test sensor spacing (2-10cm). Results: In all three groups as sensor spacing increased; i) the frequency of identified antegrade and retrograde PSs decreased; , 5% of the propagating activity observed at 1cm spacing could be seen at 10cm (P , 0.0001); ii) the ratio of antegrade to retrograde PSs increased (P , 0.0001), from pre-dominantly retrograde activity at 1cm spacing to predominantly antegrade at 10cm spacing; & iii) the number of falsely labeled PSs (when compared to 1cm data) increased (P , 0.003). At a sensor spacing .5cm the only PSs that can be reliably detected are those of high amplitude and slow propagation velocity; (real vs false amplitude: 138 vs 29 (+/12 SEM) mmHg; real vs false velocity: 5 vs 20 (+/3 SEM) mm/s). Conclusions: 1) Inadequate proximity between recording sites (resolution) results in both missed and mis-labeling of colonic propagating sequences. 2) An inter-recording site distance . 5cm grossly misrepresents colonic manometric patterns. 3) High resolution colonic manometry is likely to assist in the identification of diagnostically relevant manometric markers of colonic motor disorders. Supported by NHMRC and CSIRO Australia (1) Dinning PG et al. Br J Surg. 99: 1002-1010.

Tu2069 Characterization of the Colonic Meal Response in Healthy Controls and Patients With Slow Transit Constipation: Initial Results From Fibre-Optic High-Resolution Manometry

While colonic manometry has helped to defined dysmotility in patients with functional colonic or anorectal disorders, identification of specific manometric markers that assist in subtyping these disorders remains elusive. Typically colonic manometry is recorded with sensor spacing ≥10cm, however we have shown that colonic propagated sequences (PS) can extend over segments as short as 3-5cm(1). It is likely, therefore that traditional manometry is overlooking potentially relevant motor patterns. Aim: To determine the influence of pressure sensor spacing on our ability to accurately identify colonic motility patterns. Method: A fibre-optic catheter containing 72-90 sensors spaced at 1cm intervals was placed colonoscopically to the caecum in 11 patients with scintigraphically confirmed slow transit constipation. Controls comprised 11 patients with neurogenic fecal incontinence and 9 healthy subjects. From each of these recordings a 2hr section of trace was selected to assess motor response to either the response to a 1000kCal meal (healthy controls) or the colonic response to sacral nerve stimulation (patient population). Each data set was analysed in 6 different ways by sub-sampling different sets of the full array to simulate inter-recording site distances of 10, 7, 5, 3, 2 and 1cm. In blinded fashion, in each manometric trace antegrade and retrograde propagating sequences (PS) were identified. Against the 1cm spaced data (gold standard), we compared all the PSs identified at each test sensor spacing (2-10cm). Results: In all three groups as sensor spacing increased; i) the frequency of identified antegrade and retrograde PSs decreased; , 5% of the propagating activity observed at 1cm spacing could be seen at 10cm (P , 0.0001); ii) the ratio of antegrade to retrograde PSs increased (P , 0.0001), from pre-dominantly retrograde activity at 1cm spacing to predominantly antegrade at 10cm spacing; & iii) the number of falsely labeled PSs (when compared to 1cm data) increased (P , 0.003). At a sensor spacing .5cm the only PSs that can be reliably detected are those of high amplitude and slow propagation velocity; (real vs false amplitude: 138 vs 29 (+/12 SEM) mmHg; real vs false velocity: 5 vs 20 (+/3 SEM) mm/s). Conclusions: 1) Inadequate proximity between recording sites (resolution) results in both missed and mis-labeling of colonic propagating sequences. 2) An inter-recording site distance . 5cm grossly misrepresents colonic manometric patterns. 3) High resolution colonic manometry is likely to assist in the identification of diagnostically relevant manometric markers of colonic motor disorders. Supported by NHMRC and CSIRO Australia (1) Dinning PG et al. Br J Surg. 99: 1002-1010.

The effect of sacral nerve stimulation on distal colonic motility in patients with faecal incontinence

Sacral nerve stimulation (SNS) is an effective treatment for neurogenic faecal incontinence (FI). However, the clinical improvement that patients experience cannot be explained adequately by changes in anorectal function. The aim of this study was to examine the effect of SNS on colonic propagating sequences (PSs) in patients with FI in whom urgency and incontinence was the predominant symptom. In patients with FI a high-resolution fibre-optic manometry catheter, containing 90 sensors spaced at 1-cm intervals, was positioned colonoscopically and clipped to the caecum. A unipolar or quadripolar tined electrode was implanted into the S3 sacral nerve foramen. Colonic manometry was evaluated in a double-blind randomized crossover trial, using true suprasensory stimulation or sham stimulation. Each stimulation period, lasting 2 h, was preceded by a 2-h basal manometric recording. All 11 patients studied showed a colonic response to SNS. In ten patients there was a significant increase in the frequency of retrograde PSs throughout the colon during true stimulation compared with sham stimulation (P = 0·014). In one outlier, with baseline retrograde PS frequency nine times that of the nearest patient, a reduction in retrograde PS frequency was recorded. Compared with sham stimulation, SNS had no effect on the frequency of antegrade PSs or high-amplitude PSs. SNS modulates colonic motility in patients with faecal urge incontinence. These data suggest that SNS may improve continence and urgency through alteration of colonic motility, particularly by increasing retrograde PSs in the left colon.

Total Mesorectal Excision with Intraoperative Assessment of Internal Anal Sphincter Innervation Provides New Insights into Neurogenic Incontinence

The aim of this prospective study was to assess internal anal sphincter (IAS) innervation in patients undergoing total mesorectal excision (TME) by intraoperative neuromonitoring (IONM). Fourteen patients underwent TME. IONM was carried out through pelvic splanchnic nerve stimulation under continuous electromyography of the IAS. Anorectal function was assessed with the digital rectal examination scoring system and a standardized questionnaire. Nine of 11 patients who underwent low anterior resection had positive IONM results, with stimulation-induced increased IAS electromyographic amplitudes (median 0.23 μV (interquartile range [IQR] 0.05, 0.56) vs median 0.89 μV (IQR 0.64, 1.88), p < 0.001) after TME. The patients with the positive IONM results were continent after stoma closure. Of 2 patients with negative IONM results, 1 had fecal incontinence after closure of the defunctioning stoma and received a permanent sigmoidostomy. In the other patient the defunctioning stoma was deemed permanent due to decreased anal sphincter function. In 3 patients who underwent abdominoperineal excision, IONM assessed denervation of the IAS after performance of the abdominal part. This study demonstrated that IONM of IAS innervation in rectal cancer patients is feasible and may predict neurogenic fecal incontinence.

Acute effect of electrical stimulation of the dorsal genital nerve on rectal capacity in patients with spinal cord injury

Constipation and fecal incontinence are considerable problems for most individuals with spinal cord injury (SCI). Neurogenic bowel symptoms are caused by several factors including abnormal rectal wall properties. Stimulation of the dorsal genital nerve (DGN) can inhibit bladder contractions and because of common innervation inhibitory effects are anticipated in the rectum too. Therefore, DNG could have a future role in the treatment of neurogenic fecal incontinence. To study the effect of acute DGN stimulation on the rectal cross sectional area (CSA) in SCI patients. Seven patients with complete supraconal SCI (median age 50 years) were included. Stimulation was applied via plaster-electrodes using an amplitude of twice the genito-anal reflex threshold (pulse width: 200 μs; pulse rate: 20 Hz). A pressure controlled phasic (10, 20 and 30 cmH(2)O) rectal distension protocol was repeated four times with subjects randomized to stimulation during 1st and 3rd distension series or 2nd and 4th distension series. The rectal CSA and pressure were measured using impedance planimetry and manometry. All patients completed the investigation. Median stimulation amplitude was 51 mA (range 30-64). CSA was smaller during stimulation and differences reached statistical significance at distension pressures of 20 cmH(2)O (average decrease 9%; P = 0.02) and 30 cmH(2)O (average decrease 4%; P = 0.03) above resting rectal pressure. Accordingly, rectal pressure-CSA relation was significantly reduced during stimulation at 20 (P=0.03) and 30 cmH(2)O distension (P=0.02). DGN Stimulation in patients with supraconal SCI results in an acute decrease of rectal CSA and the rectal pressure-CSA relation.

Sacral Nerve Stimulation Alters the Frequency of Colon Propagating Sequences in Patients With Neurogenic Fecal Incontinence

Sacral Nerve Stimulation Alters the Frequency of Colon Propagating Sequences in Patients With Neurogenic Fecal Incontinence

Postanal repair – do the long‐term results justify the procedure?

Early outcomes after postanal repair (PAR) demonstrated excellent results but subsequent reports showed an ever declining success rate in maintaining continence. The aim of this study was to document long-term continence after PAR and relate this to patient satisfaction and quality of life. Patients with neurogenic incontinence who underwent PAR from 1986 to 2002 were interviewed by telephone, utilizing a questionnaire which assessed continence, patient satisfaction, overall improvement, and quality of life. One-hundred one patients from four surgeons were identified. Fifty-four patients were excluded because of loss to follow-up. Three had a stoma (two for incontinence), four had undergone a graciloplasty, leaving 57 patients (F = 53), mean duration of follow-up of 9.1 years (2.2-18.7 years). Mean CCS was 11.7 (SD 7.4). 26% (n = 15) scored none to minimal incontinence (CCS 0-5), 26% moderate (CCS 6-12), and 48% (n = 27) severe incontinence (CCS 13-24). 79% (n = 45) were satisfied with the outcome. A low CCS significantly correlated with good patient satisfaction, and was influenced by high QOL score (P < 0.0001). A high CCS significantly correlated with high bowel frequency (P = 0.0007). A favourable CCS was associated with a good QOL, a shorter duration of follow-up, and being able to distinguish flatus and stool. In patients with neurogenic faecal incontinence selected following anorectal physiology studies, PAR remains a useful treatment. It is associated with low morbidity and results in a satisfactory long-term subjective outcome, despite the fact that many patients have a high incontinence score.

Percutaneous cecostomy in the management of organic fecal incontinence in children

To assess the effectiveness and safety of imaging-guided percutaneous cecostomy in the management of pediatric patients with organic fecal incontinence. Twenty three cecostomies were performed on 21 children with organic fecal incontinence (13 males, 8 females), aged from 5 to 16 years (mean 9.5 years). Thirteen patients had neurogenic fecal incontinence and 8 patients had anorectal anomalies. Procedures were performed under general anesthesia and fluoroscopic guidance. Effectiveness and complication data were obtained for at least 1 year after the procedure. Cecostomy was successful in 20 patients (primary technical success rate 95%). Cecostomy failed in one patient due to tube breakage (secondary technical success rate 100%). The tubes were in situ for an average of 18 mo (range 12-23 mo). Eighteen patients (87%) expressed satisfaction with the procedures. Resolution of soiling was achieved in all patients with neurogenic fecal incontinence (100%) and in 5 of 8 patients with anorectal anomalies (62.5%). Eleven patients (52%) experienced minor problems. No major complications were noted. Percutaneous cecostomy improves the quality of life in children with organic fecal incontinence. A satisfactory outcome is more prevalent in patients with neurogenic fecal incontinence than anorectal anomalies.

Sacral Nerve Stimulation in Patients After Rectal Resection—Preliminary Report

IntroductionSacral nerve stimulation is a widely accepted therapeutic option for neurogenic fecal incontinence. More recently, case reports showed a positive effect of sacral nerve stimulation in patients with fecal incontinence following low anterior resection. The purpose of this study was to gain more information for this selected indication for sacral nerve stimulation through a nationwide survey. Material and methodsIn the period 2002 to 2005, three Austrian departments reported data of patients who underwent SNS for fecal incontinence following rectal resection. Data were available of seven patients (two female, five male) with a median age of 57 years (min 42; max 79). Six patients had undergone rectal resection as a treatment for low rectal cancer. One patient had undergone rectal resection for Crohn’s disease, one patient subtotal colectomy and ileorectostomy for slow colon transit constipation. ResultsTest stimulation was performed in the foramen S3 unilaterally over a median period of 14 days (2–21 days). Seven patients reported a marked reduction of episodes of incontinence during the observation period and received a permanent stimulation system. After a median follow-up of 32 months (17–46), five patients reported a marked improvement of their continence situation. ConclusionDespite a nationwide survey experiences with SNS as a treatment for fecal incontinence following rectal resection is still limited. Our observations show an improvement of the continence function following SNS. However, the promising results of our series as well as others need further research and more clinical data by a larger number of patients in a prospective trial.

Optimizing electrode implantation in sacral nerve stimulation—an anatomical cadaver study controlled by a laparoscopic camera

Sacral nerve stimulation is the therapy of choice in patients with neurogenic faecal and urine incontinence, constipation and some pelvic pain syndromes. The aim of this study is to determine the best insertion angles of the electrode under laparoscopic visualization of the sacral nerves. Five fresh cadaver pelvises were dissected through an anterior approach of the presacral space, exposing the ventral sacral roots. Needles and electrodes were inserted into the S3 foramen. Both right and left sides were used, with the traditional percutaneous procedure. The validation was done by a laparoscopic camera controlling the position of the needle and electrode on the nerve. The angles were assessed with a goniometer and were confirmed in two living patients. The mean angle of insertion in the sagittal plane was 62.9+/-3 degrees (range, 59-70). In the axial plane, the mean angle for the left side was 91.7+/-13.5 degrees (range, 80-110) and 83.2+/-7.7 degrees for the right side (range, 75-95). These angles resulted in the optimal placement of the leads along the S3 sacral root, in all these cases. This study allows direct visualization during the placement of the needle and electrode, thus permitting accurate calculations of the best angle of approach during the surgical procedure in sacral nerve stimulation. These objective findings attempt to standardize this technique, which is often performed with the aid of intra-operative fluoroscopy but still leaving a lot to chance. These insertion angles should help to find more consistent and reproducible results and thus improved outcome in patients.

Sacral nerve stimulation for neurogenic faecal incontinence

Sacral nerve stimulation (SNS) has emerged as a promising technique for the treatment of faecal incontinence. This study assessed the outcome of SNS in a cohort of patients with incontinence of neurological aetiology. Thirty-six patients were included in a trial of SNS. Twenty-nine subsequently had a permanent implant. Evaluation consisted of a continence diary, anal manometry, saline retention testing and quality of life assessment. After a median follow-up of 35 (range 3-71) months, 28 patients showed a marked improvement in or complete recovery of continence. Incontinence to solid or liquid stool decreased from a median of 7 (range 4-15) to 2 (range 0-5) episodes in 21 days (P = 0.002). Saline retention time increased from a median of 2 (range 0-5) to 7 (range 2-15) min (P = 0.002). Maximum resting and squeeze anal canal pressures increased compared with preoperative values. Quality of life on all scales among patients who received a permanent implant increased at 12 and 24 months after operation. SNS is of value in selected patients with neurogenic faecal incontinence.

Neurogenic fecal incontinence: A new look at an old problem

Neurogenic fecal incontinence: A new look at an old problem

Decreased sensitivity of muscarinic but not 5-hydroxytryptamine receptors of the internal anal sphincter in neurogenic faecal incontinence.

Previous studies of the internal anal sphincter in patients with neurogenic faecal incontinence have indicated an abnormality of the adrenergic innervation, but little is known about the responsiveness of other receptors in the internal and sphincter in this condition. In this study the in vitro sensitivity to carbachol and 5-hydroxytryptamine (5-HT) of muscle strips from patients with neurogenic incontinence (n = 6 and n = 7) and from control patients (n = 9 and n = 10) was examined. Preparations of internal and sphincter from patients with incontinence were less sensitive to the relaxant actions of carbachol than preparations from the control group. The pD2 value for carbachol (i.e. the negative logarithm of the concentration for half-maximal response) was significantly greater in the controls than in the incontinent group (mean(s.e.m.) 6.03(0.15) versus 5.43(0.24), P < 0.05). There was no significant difference in the contractile responses to 5-HT, which had pD2 values of 6.93(0.13) and 6.63(0.27) for the control and incontinent groups respectively. The unaffected state of the 5-HT receptor and the subsensitivity of the muscarinic receptor are discussed in relation to intrinsic neural control of the internal and sphincter in neurogenic faecal incontinence.

Internal anal sphincter dysfunction in neurogenic faecal incontinence.

Forty-eight patients of median age 57 years with neurogenic faecal incontinence and 44 normal subjects of median age 51 years underwent fine-wire anal sphincter electromyography and anal manometry. The median (interquartile range (i.q.r.)) internal anal sphincter (IAS) electromyogram frequency was 0.26 (0.21-0.32) Hz for patients with faecal incontinence and 0.44 (0.31-0.55) Hz for controls (P < 0.01). The median (i.q.r.) ambulatory resting pressure was 48 (34-68) cmH2O for patients and 86 (72-102) cmH2O for controls (P < 0.01) and median (i.q.r.) frequency of transient IAS relaxations 9 (7-12) and 4 (3-7) per h respectively (P < 0.05). Mid-anal pressure fell to a greater extent in patients with incontinence during these episodes of transient IAS relaxation. Rectal pressure during such relaxation did not exceed mid-anal canal pressure in controls; for the patient group, rectal pressure increased during relaxation and exceeded mid-anal canal pressure in 36 cases. Frequent abnormal episodes of IAS relaxation may cause occult faecal leakage in patients with neurogenic faecal incontinence.

Clinical assessment and anorectal manometry before postanal repair: Failure to predict outcome

It has been suggested that preoperative measurement of resting anal canal pressure and internal sphincter function can be used to identify those patients with neurogenic faecal incontinence who are unlikely to benefit from the operation of postanal repair. We have therefore analysed the results of the operation in 62 patients (six men and 56 women, mean age 59 years, range 30-83 years) and related clinical outcome to preoperative assessment of: resting anal canal pressure, the presence of gape and a combination of gape and low resting pressure. None of these factors was found to predict a poor result after postanal repair.

Rectoanal inhibition and incontinence in patients with rectal prolapse.

Thirty-five patients with complete rectal prolapse, 32 with neurogenic faecal incontinence and 33 controls underwent ambulatory recording using a computerized anal electromyographic and anorectal manometry system. Median resting anal pressures were 34 cmH2O in patients with prolapse, 51 cmH2O in those with neurogenic faecal incontinence and 94 cmH2O in controls. Median basal rectal pressures were 18, 21 and 21 cmH2O respectively. High-pressure rectal waves of median amplitude 71 cmH2O lasting 30-150 s and associated with inhibition of the electromyographic activity of the internal and sphincter and a fall in anal pressures were seen in all patients with prolapse but not in controls or those with neurogenic incontinence. These waves were abolished following successful resection rectopexy. Recovery of continence occurs by abolition of high-pressure rectal waves, which produce maximal inhibition of sphincter activity before operation.

Prospective study of the effects of postanal repair in neurogenic faecal incontinence

The most important factor associated with a good result in the surgical treatment of neurogenic faecal incontinence by postanal repair is considered to be restoration of the obtuse anorectal angle. Sixteen patients (14F:2M; median age 59 years) with neurogenic faecal incontinence confirmed by a raised fibre density in the external anal sphincter underwent postanal repair. Pre- and postoperative manometric assessment was performed in 16 and radiological assessment in 12. Normal ranges for these parameters were established in age and sex matched control subjects. Continence was improved in 14 (88 per cent) patients, 6 (38 per cent) of whom regained normal continence, at a minimum of 15 months follow-up. A successful outcome was associated with no significant change in basal (pre-operative 35 (10-85) cmH2O, postoperative 44 (12-105) cmH2O; n.s.) or voluntary (pre-operative 43 (5-150) cmH2O, postoperative 32 (12-180) cmH2O; n.s.) components of anal canal pressure. There was a small but significant increase in sphincter length (pre-operative 2 (0-3) cm, postoperative 2.5 (0-3.5) cm; P less than 0.01). There was no significant change in the anorectal angle at rest (pre-operative 96 (90-110) degrees, postoperative 107 (79-118) degrees; n.s.) in the patients in whom continence was restored and five of these patients had resting anorectal angles within the normal range (75-94 degrees). Thus postanal repair need not be restricted to patients with widening of the anorectal angle since its beneficial effects do not appear to be related to reduction of this angle.