True Fecal Incontinence Research Articles

True Fecal Incontinence and Its management In Children: Review Article

True Fecal Incontinence and Its management In Children: Review Article

Діагностика та лікування анальної інконтиненції після хірургічної корекції вродженої аноколоректальної патології в дітей

Fecal incontinence (FI) in children is a serious medical and social problem. FI leads to severe limitations in a child’s development and social adaptation. Pediatric surgeons mainly deal with the mechanical type of FI that occurs after surgical correction of anorectal malformations (ARM) or Hirschsprung's disease (HD). Violation of defecation control is observed in 53-89% of patients who underwent surgery for ARM and HD. Purpose - to study the causes and effectiveness of the proposed complex treatment of FI in children operated on for HD and ARM. Materials and methods. Clinical examination and treatment of 92 children with congenital pathology of the distal colon and anus (55 (59.78%) patients with HG and 37 (40.22%) with ARM) was carried out at the Pediatric Surgery Clinic of Ivano-Frankivsk National Medical University. Among the surveyed children were 64 boys and 28 girls (ratio - 2.29:1). In terms of age, newborns and children of the first year of life predominated among those who underwent primary surgery - 57 (61.95%) children. FI of varying severity was detected in 48 (52.17%) patients operated on for HD and ARM at different terms after surgical correction - from 6 months to 3 years. The types, causes, and severity of FI in each child were studied. In addition to conventional clinical and instrumental studies, patients underwent anoscopy and rectoscopy, transanal ultrasound, anorectal manometry. The severity of AI was assessed on a S.D. Wexner score. Results. FI occurred in 34 (70.8%) children after HD correction and in 14 (29.2%) patients after ARM surgery. True FI was found in 33 (68.75%) children. Pseudoincontinence was detected in 15 (31.25%) patients it was more common in patients operated on for HD. For conservative treatment of patients with FI a Bowel Management Program was implemented. In 24 (50.0%) patients treated according to this program, the control of defecation was significantly improved, the incontinence severity index was significantly reduced according to the Wexner score. In true AI due to severe anal sphincter damage, we performed minimally invasive surgical correction of postoperative insufficiency or congenital defect of the internal sphincter of the anus using a volume-forming implant in 14 (29.17%) children. Immediate and long-term results of the operation were good, which was reflected in improved control of defecation, a significant increase of basal pressure and a decrease of the incontinence severity index. Conclusions. Tactics of the FI treatment depends on the cause and severity. The implementation of the Bowel Management Program can significantly improve the control of defecation and improve the quality of life of patients. In case of insufficiency of the internal anal sphincter, minimally invasive correction by anal submucosal implantation of a volume-forming gel is effective. The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of the participating institution. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the authors. Keywords: fecal incontinence, anorectal malformations, Hirschsprung's disease, children.

A PROSPECTIVE RANDOMISEDSTUDY COMPARINGLATERAL INTERNAL SPHINCTEROTOMY AND ANAL DILATATIONFOR THE MANAGEMENT OF CHRONIC ANAL FISSURE

Background: Lateral internal sphincterotomy (LIS) is a surgical procedure which is performed routinely in the treatment of chronic anal fissures, especially in cases that have failed traditional medical modalities. Controlled application of a Parks retractor was found to be an alternative method8,9 and with standardization, 88% healing 10 with a 12% recurrence were achieved in a large series. In this retrospective study, we compared intermittent dilation using Parks dilator with a standard LIS method to see the effect on chronic fissures management. Aims and objectives:Both anal dilatation and internal anal sphincterotomy are practiced in our hospital for treatment of chronic anal fissure, The objectives of the study was to compare the two procedures especially regarding pain relief,ulcer healing,incontinence and recurrence . Materials and methods:This study was carried out at Maharani Laxmi Bai Medical College, Jhansi, Uttar Pradesh from october 2020 to September 2021 on a pool of 100 patient out of which, 50 underwent anal dilation using Parks dilator (AD) and 50 underwent LIS. AD patients were discharged on the same day while LIS patients were discharged on post op day 2. Approval for the study was obtained fromthe ethical committee of the college. Results: 100 patients were studied and followed up.Pain was present in all the 100 (100%) patients and bleeding in 81 (82.6%) patients. Average duration of symptoms was 11.16 ± 12.17 (range, 1.8-60 months) and the difference between two groups was not significant. No patient had significant intraoperative complications. Four patients in LIS group complained of pain and some discharge on the fifth post-operative day.The average follow-up was 9 months. Pain relief was observed in 30 (Group A) and 35 (Group B) patients by the end of 1 week and 45 (Group A) and 50 (Group B) patients by the end of 1 month. By one month, healing of the ulcer was observed in 35 and 38 patients in group A and B respectively. By the end of 3 months, minor incontinence including mucous discharge was observed in 18 and 6 patients in group A and B respectively and the difference was significant (p=0.0062). True fecal incontinence occurred only in 2 patients in group A and was minor. No patient had major incontinence. A few among these patients who followed up till late, incontinence was found to gradually improve. Regarding recurrence, over the period of 9 months follow-up, 9 and 2 patients in group A and group B respectively reported with recurrence of symptoms and the fissure was evident on examination also (p =0.0075) Conclusions Both AD and LIS provides early pain relief and high ulcer healing rate. However, LIS appears to be safer with regard to incontinence, and the chance of recurrence is also lower compared to AD.

Результати реконструктивних операцій при вродженій аноколоректальній патології в дітей

Fecal incontinence (FI) in children is a serious medical and social problem. FI leads to severe limitations in a child’s development and social adaptation. Pediatric surgeons mainly deal with the mechanical type of FI that occurs after surgical correction of anorectal malformations (ARM) or Hirschsprung's disease (HD). Violation of defecation control is observed in 53-89% of patients who underwent surgery for ARM and HD. Purpose - to study the causes and effectiveness of the proposed complex treatment of FI in children operated on for HD and ARM. Materials and methods. Clinical examination and treatment of 92 children with congenital pathology of the distal colon and anus (55 (59.78%) patients with HG and 37 (40.22%) with ARM) was carried out at the Pediatric Surgery Clinic of Ivano-Frankivsk National Medical University. Among the surveyed children were 64 boys and 28 girls (ratio - 2.29:1). In terms of age, newborns and children of the first year of life predominated among those who underwent primary surgery - 57 (61.95%) children. FI of varying severity was detected in 48 (52.17%) patients operated on for HD and ARM at different terms after surgical correction - from 6 months to 3 years. The types, causes, and severity of FI in each child were studied. In addition to conventional clinical and instrumental studies, patients underwent anoscopy and rectoscopy, transanal ultrasound, anorectal manometry. The severity of AI was assessed on a S.D. Wexner score. Results. FI occurred in 34 (70.8%) children after HD correction and in 14 (29.2%) patients after ARM surgery. True FI was found in 33 (68.75%) children. Pseudoincontinence was detected in 15 (31.25%) patients it was more common in patients operated on for HD. For conservative treatment of patients with FI a Bowel Management Program was implemented. In 24 (50.0%) patients treated according to this program, the control of defecation was significantly improved, the incontinence severity index was significantly reduced according to the Wexner score. In true AI due to severe anal sphincter damage, we performed minimally invasive surgical correction of postoperative insufficiency or congenital defect of the internal sphincter of the anus using a volume-forming implant in 14 (29.17%) children. Immediate and long-term results of the operation were good, which was reflected in improved control of defecation, a significant increase of basal pressure and a decrease of the incontinence severity index. Conclusions. Tactics of the FI treatment depends on the cause and severity. The implementation of the Bowel Management Program can significantly improve the control of defecation and improve the quality of life of patients. In case of insufficiency of the internal anal sphincter, minimally invasive correction by anal submucosal implantation of a volume-forming gel is effective. The research was carried out in accordance with the principles of the Helsinki declaration. The study protocol was approved by the Local ethics committee of the participating institution. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the authors. Key words: fecal incontinence, anorectal malformations, Hirschsprung's disease, children.

To Study the Outcome of Posterior Sagittal Anorectoplasty in Anorectal Malformations

Aim: To assess the effectiveness of posterior sagittal anorectplasty for the repair of anorectal malformations in terms of postoperative complications and functional outcomes. Study design: Descriptive prospective study. Place and duration of study: Sahiwal Teaching Hospital, Sahiwal. From 1st January 2016 to 31st December 2019. Methodology: Forty-two children with high/intermediate anorectal malformations, who underwent posterior sagittal anorectoplasty, were included in the study. Patients with low variety anorectal malformations, recto vestibular/ano vestibular fistula, persistent cloaca and patients with sacral dysraphism, spinal dysraphism, myelomeningocele spina bifida occulta and menifesta were excluded. Demographic information included age, gender, weight, type of anorectal malformation, type of surgery performed, operation time and hospital stay. Immediate post-operative complications were also noted. Bowel habits, constipation and faecal incontinence were evaluated in all patients during the follow up period. Results: Thirty-one (73.80%) were males and 11(26.19%) were females and mean age was 1.72 years. The mean weight at the time of operation was 11.00 kg. High variety anorectal malformations were 14(33.33%) and intermediate were 28(66.66%). Rectourethral fistula 25(59.52%) was most common variety seen in males. Recto bulber urethral fistula in 17(40.47%) and recto prostatic urethral fistula in 8(19.04%) patients were seen. Anal agenesis without fistula 7(16.66%) was most common anomaly in females. Overall complication rate was 15(35.71%). Constipation 11(26.19%) was most common post-operative complication. True fecal incontinence was seen in 3(7.14%) patients. Strong and effective squeeze of anal sphincter was seen in 39 (92.85%) patients and satisfactory bowel habits were present in 37 (88.08%) patients. Conclusion: Posterior sagittal anorectplasty is a useful procedure in the management of high/intermediate anorectal malformations, precise identification and reconstruction of muscle complex result in good anatomical and functional outcome. Immediate post-operative complication rate is also low. Keywords: Anorectal malformations, Posterior Sagittal Anorectoplasty, Postoperative complications, Functional outcomes

A technique to reconstruct the anal sphincters following iatrogenic stretching related to a pull-through for Hirschsprung disease

Soiling and fecal incontinence are troubling complications which can occur after a pull-through for Hirschsprung disease. They can usually be improved with proper medical management, but in some cases are the result of an anatomic defect related to overstretching of the sphincters and/or damage of the anal canal. For such patients the treatment of this true fecal incontinence is limited to a structured bowel management program with ante- or retrograde enemas to achieve social continence. Herein we report two such patients with overstretched sphincters and loss of the dentate line after an initial pull-through and describe a sphincter tightening technique to improve bowel control.

Hirschsprung's disease

Hirschsprung's disease (HD) is a congenital functional disorder characterized by the absence of ganglion cells in the enteric nervous system. The estimated incidence of HD is 1:5000 with up to 60% of patients having associated anomalies. Short-segment rectosigmoid disease is seen in 75% of cases with infants presenting with abdominal distension, bilious vomiting and delayed passage of meconium. A bedside rectal suction biopsy is the gold-standard in confirming the diagnosis of HD. The absence of ganglion cells in the myenteric and submucosal plexi in the presence of thickened hypertrophic nerves (more than 40 microns diameter) is diagnostic of HD. There are no medical options to treat HD, however rectal washouts can be used to bridge the gap to surgery. Contemporary management of this condition involves a single-stage pull-through that can be performed using various techniques including minimal access surgery. Long-term problems in with HD are common and these include obstructive symptoms (10–30%), constipation (10–15%), enterocolitis (10–15%) and true faecal incontinence (1–2%). Furthermore 20–30% of adults report symptoms of incontinence and constipation as well as poor sexual function. Future research is being focussed on novel gene therapies including stem-cell therapy and the use of CRISPR/CA9 to edit parts of the genome.

Antegrade Continence Enema

Abstract The broad term “ACE” refers to an antegrade continence enema that allows you to flush or empty the colon starting from the beginning of the colon (cecum) and flushing to the end (rectum) for patients with true fecal incontinence or constipation with the inability to empty the bowel with oral therapy. The terms “cecostomy,” “MACE,” “ACE,” and “Malone” have often been used interchangeably; however, they do have technical differences. The purpose of this article is to describe and compare specifically Malone/appendicostomy, neo-Malone/neo-appendicostomy, and cecostomy. The contents of this publication are compiled of both expert opinions and literature review.

Surgical approach for fecal incontinence with a patulous anus after transanal pull-through for Hirschsprung disease

BackgroundWe have performed transanal pull-through (TAPT) for Hirschsprung disease since 1998. Some of our patients after TAPT showed a patulous anus and suffered from severe true fecal incontinence. We performed anal canal plasty for these patients and evaluated its efficacy in restoring anorectal function. MethodsThirty-one patients who were ≥5years old were previously operated on for Hirschsprung disease, and seven (22.5%) of these were indicated for this procedure. Anorectal function was evaluated using the Japanese Study Group of Anorectal Anomalies (JSGA) clinical assessment of defecation function score. For surgery, the patients were positioned in the prone jackknife posture. The posterior half of the anal canal was exposed and folded inward until the anal canal lumen was as narrow as the surgeon's index finger. External anal sphincter muscles were repaired, and the wound was closed vertically. ResultsThe mean preoperative JSGA score was 1.42±0.4. The mean JSGA scores at 2–6months and 2years after this procedure were 5±2.1 and 5.8±2.1, respectively. Postoperatively, the JSGA score significantly improved at both times (p<0.05). ConclusionsAnal canal plasty may be effective for true fecal incontinence and a patulous anus after TAPT. This surgical approach may be useful for these conditions. Level of evidenceType of study: Treatment study, Level IV.

Damaged anal canal as a cause of fecal incontinence after surgical repair for Hirschsprung disease – a preventable and under-reported complication

IntroductionFecal incontinence after the surgical repair of Hirschsprung disease is a potentially preventable complication that carries a negative impact on patient's quality of life. MethodsPatients that were previously operated for Hirschsprung disease and presented to our bowel management clinic with the complaint of fecal incontinence were retrospectively reviewed. All patients underwent a rectal examination under anesthesia looking for anatomic explanations for their incontinence. ResultsOne hundred three patients were identified. 54 patients had a damaged anal canal. 22 patients also had a patulous anus. The operative reports mentioned the pectinate line in 32 patients, in 12 it was not mentioned, and in 10 patients the operative report was not available. All patients with a damaged anal canal suffered from true fecal incontinence; 45 of them are on daily enemas (41 are clean and 4 are still having “accidents”), 7 are not doing bowel management due to noncompliance and 2 patients have a permanent ileostomy. 49 patients did not have a damaged anal canal, 25 of those responded to changes in diet and medication and are having voluntary bowel movements. ConclusionFecal incontinence may occur after an operation for Hirschsprung disease. When the anal canal is damaged, incontinence is always present, severe, and probably permanent. The preservation of the anal canal may avoid this complication.

Prognostic evaluation of biofeedback response in patients treated for anorectal malformation

PurposeFunctional bowel outcome in patients with anorectal malformation often is poor. For fecal incontinence resulting from sphincter dysfunction, biofeedback (BFB) training appears to be effective. The aim of study was to investigate the bowel function in incontinent children treated for ARM, using a clinical score, a manometric and pelvic magnetic resonance evaluation, in order to establish predictive parameters of response after BFB. Methods25 children (median age of 6.5years) with true fecal incontinence were evaluated by clinical score, anorectal manometry and magnetic resonance imaging (MRI). According to these evaluations patients were divided in 4 groups: group 1 (favorables manometry and MRI); group 2 (favorable manometry and unfavorable MRI); group 3 (unfavorable manometry and favorable MRI); group 4 (unfavorables manometry and MRI). All groups started a cycle of BFB and six months after end of BFB, were reevaluated by clinical score and manometry. ResultsThe overall response to BFB was excellent in 44%, discrete in 40% and poor in 16%; a better response was found in groups 1 and 2 than groups 3 and 4. The differences between groups before BFB proportionally correlated with values after BFB; a correlation with genitourinary and spinal anomalies was found. ConclusionsOur results showed that BFB is an effective for fecal incontinence when the assessment pretreatment (functional and morphologic) is favorable; the manometry can evaluate the potential sphincterial recovery after BFB with a further prognostic benefit if correlated to morphologic evaluation with MRI.

Hydrocolonic sonography: a helpful diagnostic tool to implement effective bowel management

Fecal incontinence is a serious problem that may lead to social segregation and psychological problems. Patients with anorectal malformations frequently suffer from fecal incontinence even with an excellent anatomic repair. In these patients, an effective management program with enemas can improve their quality of life. We want to present our experience with hydrocolonic sonography as a diagnostic tool to predict the type and volume of enema needed to initiate an effective bowel management. Patients who presented with soiling regardless of the type of anomaly were included in the study. Thirty patients aged 4-18 were evaluated. The diagnostic program comprised a careful clinical history, physical examination, exact classification of the malformation, evaluation for associated defects, and stool protocol. Twenty patients suffered from true fecal incontinence and were included in a bowel management program. These patients received oral polyethyleneglycol to evacuate stool impaction. Bowel management was initiated with the help of hydrosonography to evaluate bowel motility. The volume of the enema was determined according to the amount of fluid that was needed to fill the colon to the cecum. Twenty patients were investigated with the help of hydrocolonic sonography. Eighteen patients were free of symptoms of soiling after 3 days of hospital treatment and remained free of symptoms 6 months and 1 year later at reevaluation. Two patients did not follow the therapeutic regime and, therefore, did not show an improved condition concerning soiling in the long run. Hydrocolonic sonography is a helpful diagnostic tool to assess colonic volume and motility to predict the type and volume of enema needed for an effective bowel management.

A practical approach to the management of pediatric fecal incontinence

We describe the rationale and key aspects for success of a bowel management program for the treatment of pediatric fecal incontinence. A retrospective review was done of the medical strategies used for the treatment of over a 1000 patients with fecal incontinent, combining the experience of the authors' previously published reports (Peña A, Guardino K, Tovilla JM, et al. J Pediatr Surg 1998; 33:133-137 and Bischoff A, Levitt MA, Bauer C, et al. J Pediatr Surg 2009; 44:1278-1284) and additional treated patients after those publications. Emphasis was placed on the review of the key factors needed to achieve success. Through the years, we have learned important lessons that resulted in our current strategy which allows us to obtain better results than earlier in our series. At present, the key aspects for success are (a) to distinguish between true fecal incontinence and pseudoincontinence; (b) to determine the characteristics of the colon (dilated or nondilated), ascertained by looking at the patient's contrast enema, and determine the treatment strategy from this; (c) to monitor the result of the enema (amount of stool left in the colon) with daily abdominal radiographs during a 1-week period; and (d) to thereby modify the type of enema daily, depending on the clinical result, and the abdominal radiograph. Following a systematic rationale in the classification of patients with fecal incontinence and applying selectively, individualized management, it is possible to achieve a 95% success rate in patients suffering from fecal incontinence.

Pediatric Fecal Incontinence: A Surgeon's Perspective

1. Marc A. Levitt, MD* 2. Alberto Pena, MD* 1. *Colorectal Center for Children, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio. After completing this article, readers should be able to: 1. Describe the difference between true fecal incontinence and pseudoincontinence. 2. Understand the patient groups that suffer from true fecal incontinence. 3. Discuss the physiologic mechanisms of continence. 4. Formulate the evaluation and treatment of a patient who presents with soiling. 5. Develop a treatment protocol for constipation with overflow pseudoincontinence (encopresis). 6. Describe the primary differences between Hirschsprung disease and idiopathic constipation. Editor's Note: Fecal incontinence is a frustrating condition for patients, parents, and clinicians. This article discusses fecal incontinence caused by anatomic conditions as well as the overflow of stool that follows severe constipation. The perspective is that of the pediatric surgeon, and the discussion offers insights not always present in pediatric reviews. Some recommendations are derived from the extensive experience of the authors over many years of treating these patients. All figures for this article are contained in the data supplement Fecal soiling is a common problem that pediatricians are asked to evaluate. Fecal incontinence represents a devastating problem that may prevent a child from becoming socially accepted. More children are affected than previously believed, including those born with surgical conditions such as anorectal malformations (ARMs) and Hirschsprung disease (HD), as well as those who have spinal cord problems or injuries. Patients can have true fecal incontinence or can suffer from overflow pseudoincontinence. These two conditions have completely different treatments. Those who experience true incontinence include a percentage of surgical patients (who have ARMs and HD) as well as those who have congenital or acquired spinal problems. Pseudoincontinence (encopresis) occurs in patients who have the potential for bowel control but whose constipation leads to …

Prospective evaluation of comorbidity and psychosocial need in children and adolescents with anorectal malformation. Part one: paediatric surgical evaluation and treatment of defecating disorder

Anorectal malformations represent a continuing challenge for the paediatric surgeon. Faecal and urinary incontinence can occur even with an excellent anatomic repair. We undertook a prospective evaluation of comorbidity and psychosocial needs in children and adolescents with anorectal malformation to test the hypothesis whether psychosocial workup in concert with an improved continence situation would lead to a better functional outcome in patients suffering from defecating disorders. Treatment of defecating disorder was based on differentiation between overflow pseudo-incontinence and true faecal incontinence. Patients who presented with soiling regardless of the type of anomaly were included in the study: 44 patients were investigated, 14 patients did not meet the criteria of the study, 30 patients aged 4-18 were evaluated. The surgical diagnostic program comprised a careful clinical history, physical examination, exact classification of the malformation, evaluation for associated defects, stool protocol. Patients were grouped in two different management programs according to their continence situation. Patients with pseudo-incontinence were treated with enemas, diet, anal hygiene, behavioural therapy and physiotherapy. Patients with true faecal incontinence were included in a bowel management program: 28 patients were free of symptoms of soiling after 3 days of hospital treatment and remained free of symptoms 6 months and 1 year later at re-evaluation. Two patients did not follow the therapeutic regime and therefore did not show an improved condition concerning soiling in the long run. Differentiating between overflow pseudo-incontinence and true faecal incontinence is the basis of an effective treatment of defecating disorders. All patients born with anorectal malformation can be kept clean of stool if they are subjected to an adequate treatment. A multidisciplinary approach is a valuable supplement to standard therapy.

Functional outcome and quality of life after restorative proctocolectomy and ileo-anal pouch anastomosis.

Reconstructive proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical treatment of ulcerative colitis (UC) and familial adenomatous polyposis (FAP). The aim of our study was to evaluate the functional results of this procedure and to assess its impact upon patient quality of life (QoL). We evaluated QoL and functional results in patients who had undergone IPAA using two self-rating questionnaires: 1) Medical Outcome 36 item Health Survey (SF-36); and 2) a specific questionnaire evaluating various aspects of anorectal and urogenital function. 107 patients (median age 38 [range 17-69] years) underwent reconstructive proctocolectomy with IPAA between 1981 and 2002. Median duration of follow-up was 83 (range 4-230) months. 66 patients (61%) answered both questionnaires. Two thirds of patients have more than five bowel movements per day and one bowel movement at night. Whilst true faecal incontinence is exceptional, episodes of soiling are reported by 25% of patients. Regarding QoL in this population, the two scores of the SF-36, which summarise physical and mental health status (Physical Component Summary and Mental Component Summary) were 54.6 and 45.8, respectively (both are 50 in the general population). Our data indicate that, as measured with SF-36 questionnaire, QoL after IPAA is close to normal. However, good quality of life is not a surrogate for good functional results. Despite excellent control of continence during the day, IPAA is often associated with night time bowel movements and soiling.

Functional outcome and quality of life after restorative proctocolectomy and ileo-anal pouch anastomosis.

Reconstructive proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical treatment of ulcerative colitis (UC) and familial adenomatous polyposis (FAP). The aim of our study was to evaluate the functional results of this procedure and to assess its impact upon patient quality of life (QoL). We evaluated QoL and functional results in patients who had undergone IPAA using two self-rating questionnaires: 1) Medical Outcome 36 item Health Survey (SF-36); and 2) a specific questionnaire evaluating various aspects of anorectal and urogenital function. 107 patients (median age 38 [range 17-69] years) underwent reconstructive proctocolectomy with IPAA between 1981 and 2002. Median duration of follow-up was 83 (range 4-230) months. 66 patients (61%) answered both questionnaires. Two thirds of patients have more than five bowel movements per day and one bowel movement at night. Whilst true faecal incontinence is exceptional, episodes of soiling are reported by 25% of patients. Regarding QoL in this population, the two scores of the SF-36, which summarise physical and mental health status (Physical Component Summary and Mental Component Summary) were 54.6 and 45.8, respectively (both are 50 in the general population). Our data indicate that, as measured with SF-36 questionnaire, QoL after IPAA is close to normal. However, good quality of life is not a surrogate for good functional results. Despite excellent control of continence during the day, IPAA is often associated with night time bowel movements and soiling.

Update on Paediatric Faecal Incontinence

Faecal incontinence represents a devastating problem; it is often a barrier to social acceptance. It can affect many children including those with prior surgery (for anorectal malformations and Hirschsprung's disease) as well as those with spinal problems or injuries. Management involves distinguishing between true and pseudo-incontinence, and then determining the proper protocol of treatment. An extensive review of the authors' series of over 500 patients who presented with soiling was undertaken with the goal of determining helpful algorithms of treatment. Treatment begins first with proper categorisation of patients. Pseudo-incontinence (encopresis) can be treated with disimpaction followed by laxative therapy. True incontinence requires an enema programme, with treatment tailored to either hypo or hyper-motile colons. Surgery for pseudo-incontinence, rarely required, takes the form of colonic resection but only for patients with a demonstrated ability to have voluntary bowel movements, albeit with enormous laxative requirements. Removal of the rectosigmoid in this situation can reduce or eliminate the need for laxatives. Surgery for true faecal incontinence involves changing the route for a successfully demonstrated enema programme to an antegrade, i.e., a Malone appendicectomy. The keys to success in helping a fecally incontinent child are dedication and sensitivity on the part of the medical team. The basis of the bowel management programme is to clean the colon (either with medical treatment for patients with the potential for bowel control, or artificially with enemas for patients with true faecal incontinence), and then keep the colon quiet for 24 hours until the next treatment, thereby ensuring that the patient is clean and no longer soiling. The programme is an ongoing process of trial and error that responds to the individual patient and differs for each child. We carry out this programme over the course of one week with daily abdominal radiographs as we tailor the regimen. More than 95 % of the children who follow this programme are clean and dry. The clinician must embrace the philosophy that it is unacceptable to send a child with faecal incontinence to school in diapers when their classmates are already toilet trained. Proper treatment to prevent this is perhaps more important than any surgical procedure.

Flatus and faecal incontinence: prevalence and risk factors at 16 weeks of gestation

To evaluate the prevalence of anal incontinence at 16 weeks of gestation and to identify possible maternal and obstetrical risk factors. Cross sectional study and cohort study. Department of Obstetrics and Gynaecology, Aarhus University Hospital, Denmark. Cross sectional study: 7,557 women attending antenatal care. Cohort study: a subgroup of 1,726 pregnant women with one previous delivery at our department. The prevalence of anal incontinence within the preceding year was 8.6%. Incontinence of liquid and solid stools was reported in 2.3% and 0.6%, respectively. Isolated flatus incontinence at least once a week was reported in 4.2%. The risk of flatus incontinence at least once a week was increased with age > 35 years (OR 1.6; 95% CI 1.1-2.4) and with previous lower abdominal or urological surgery (OR 1.5, 95% CI 1-1-2.1) in a logistic regression model controlling for maternal factors. Increasing parity did not increase the risk. The risk of flatus incontinence was increased after anal sphincter tear and birthweight > 4,000 g in a logistic regression model controlling for maternal and obstetric variables. Episiotomy was insignificantly associated, while spontaneous perineal tear > 3 cm and a number of other intrapartum factors were not associated. CONCLUSION True faecal incontinence is rare among younger women. However, an age > 35 years and previous lower abdominal or urological surgery increased the risk of flatus incontinence in contrast to increasing parity. This suggests that childbirth plays a minor role compared with age. However, when analysing obstetric variables separately, a birthweight > 4,000 g, and anal sphincter tears were significant risk factors for flatus incontinence.