Urge Fecal Incontinence Research Articles

Cholestyramine – Useful Adjunct for the Treatment of Fecal Incontinence

Purpose: There are limited options for drug therapy in fecal incontinence (FI). Biofeedback therapy (BT) or surgery remain the mainstay. Cholestyramine may alleviate diarrhea and incontinence by binding to bile salts but its use in FI has not been assessed. We report our experience with the use of cholestyramine, as an adjunct to BT in the treatment of diarrhea with FI. Methods: Over a 5 yr period, 21 patients (19 F, mean age 65 yrs) with FI received standard BT (biweekly pelvic muscle strengthening exercises, mean number of sessions 6) along with cholestyramine 2–6 gm (dose titrated according to response). All patients underwent anorectal manometry and saline continence tests. Daily stool frequency, stool consistency (Bristol scale), number of incontinent episodes, and satisfaction with bowel function (VAS) were prospectively assessed at baseline, after treatment, and at 1 year. Results: There were 12 (57%) patients with predominant urge FI, 5 (24%) with passive FI, and 4 (19%) with fecal seepage. Predisposing factors for suspected bile salt malabsorption were: cholecystectomy in 7 (33%), hemicolectomy in 5 (15%), small intestinal bacterial overgrowth in 4 (19%), Crohn's disease 1 (5%), intestinal bypass in 1 (5%), and none in 3 (14%). The mean dose of cholestyramine was 3.6 ± 1.2 gm (median 4 gm). Twelve patients received 2 gm qhs, 7 received 4 gm qhs, and 2 received, 2 gm am and 4 gm qhs. Seven (33%) patients reported minor side effects that resolved with dose reduction (constipation 4, excessive gas/bloating 2, headache 1). However, one patient could not tolerate cholestyramine. Symptoms, bowel satisfaction and anorectal function improved after treatment (p < 0.05, see Table).Table 1Conclusions: In selected patients with diarrhea, urgency and incontinence, cholestyramine can serve as a safe and useful adjunct to the management of FI. Most patients require small doses (2–4 gm qhs) and dose titration is essential. The improvement in stool characteristics favors a drug effect, over and above the potential benefits with BT on bowel function.

Effect of Vaginal Pessaries on Symptoms Associated With Pelvic Organ Prolapse

To prospectively evaluate the effects of vaginal pessaries on symptoms associated with pelvic organ prolapse and identify the risk factors for failure. All women referred to a specialist urogynecology unit with symptomatic pelvic organ prolapse who elected to use a pessary were included in this study. All completed the Sheffield pelvic organ prolapse symptom questionnaire before use and after 4 months of use. The primary outcome measure was change of symptoms from baseline to 4 months. Of 203 consecutive women fitted with a pessary, 153 (75%) successfully retained the pessary at 2 weeks, and 97 completed the questionnaires at 4 months. Multivariate logistic regression analysis showed that failure to retain the pessary was significantly associated with increasing parity (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.14-2.02, P = .004) and hysterectomy (OR 4.57, 95% CI 1.71-12.25, P = .002). In the success group at 4 months (n = 97), a significant improvement in voiding was reported by 39 participants (40%, P = .001), in urinary urgency by 37 (38%, P = .001), in urge urinary incontinence by 28 (29%, P = .015), in bowel evacuation by 27 (28%, P = .045), in fecal urgency by 22 (23%, P = .018), and in urge fecal incontinence by 19 (20%, P = .027), but there was no significant improvement in stress urinary incontinence in 22 participants (23% P = .275). Of the 26 (27%) who were sexually active, 16 (17%, P = .001) reported an increase in frequency of sexual activity, and 11 (11%, P = .041) had improved in sexual satisfaction. A vaginal pessary is an effective and simple method of alleviating symptoms of pelvic organ prolapse and associated pelvic floor dysfunction. Failure to retain the pessary is associated with increasing parity and previous hysterectomy. II-3.

Effect of Parity on Sexual Function

To assess the impact of childbirth on female sexual function by using an identical twin study design. A survey including the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) was administered to 542 twin sisters, and PISQ-12 scores of 29 twin pairs discordant for parity were compared. Multiple linear regression models were used to evaluate impact on total PISQ-12 scores in 276 identical, sexually active twins. Three models were used 1) to evaluate the effect of parity and general risk factors, 2) to examine the impact of birth mode, and 3) to examine the role of episiotomy and operative delivery. Mean PISQ-12 scores were significantly higher for discordant nulliparous twins than for parous twins (102.5 versus 93.5, P < .001). The mean (standard deviation) PISQ-12 score was 99.3 (11.7). Age of 50 years or older (difference in mean scores -5.4, P = .019), stress urinary incontinence (-3.3, P = .02), urge urinary incontinence (-5.9, P < .001), parity (-6.5, P < .001), and fecal incontinence (-5.7, P = .048) were associated with decreased mean PISQ scores in the univariable analysis. Parity (-4.9, P < .001) and urge urinary incontinence (-4.3, P = .009) were the only factors remaining independently predictive of diminished sexual function in the multivariable analysis. Mode of delivery did not significantly affect mean PISQ scores (P = .763). Among women who had vaginal deliveries only, neither episiotomy nor operative delivery was associated with change in PISQ scores (P = .553). Nulliparous women reported superior sexual satisfaction scores compared with parous women, regardless of age and mode of delivery. Childbirth appears to have a lasting impact on sexual function, due to psychological more than physical factors, well beyond the postpartum period. II-2.

Low rectal volumes in patients suffering from fecal incontinence: what does it mean?

Sirs, This study explores rectal sensorimotor function in faecal incontinence (FI),1 reporting a relationship between rectal compliance, sensitivity and perception in those with reduced maximal tolerable volume to isobaric distension. However, the authors have failed to acknowledge significant contributions already published in this field. Traditionally, the focus of attention in FI has been abnormal anal sphincter function, but a multifactorial basis is emerging.2, 3 For example, Bharucha et al., have recently shown that FI is associated with puborectalis atrophy and rectal hypersensitivity (lowered rectal sensory volumes).4 Studies from our institution have also shown rectal sensory mechanisms to be important in FI.5 We examined the relationship between sensation and symptoms in patients with urge FI, and confirmed6 that up to half have rectal hypersensitivity, which is associated with increased stool frequency and urgency, compared to those patients with normal rectal sensation.5 In addition, the influence of rectal hyposensitivity (increased rectal sensory volumes) on FI has been studied, with two pathophysiologies identified: increased rectal compliance and truly disordered afferent function.7, 8 We have also reported the relationship between rectal sensation and motor function in patients with urge FI using prolonged rectosigmoid manometry,9 and shown that in the group with rectal hypersensitivity, symptoms were more prevalent and were more often temporally associated with contractile events. Furthermore, in patients with rectal hypersensitivity, an increase in frequency of high-amplitude contractions, and alteration in variables of the rectal motor complex were demonstrated, in comparison to control subjects and patients with normal rectal sensation. For individual patients, rectal hypocompliance and exaggerated rectal motor complex activity were only found in those with rectal hypersensitivity.9 With regard to the authors’ concluding statement: ‘…a better recognition of physiological impairment may enlarge the fields of rectal surgery in selected patients, suffering from incontinence with low compliant rectum, thus bringing it into a similar perspective than bladder surgery’, it is disappointing that the rectal augmentation procedure, developed in our institution for these reasons, has not been discussed.10 In patients with urge FI, secondary to a deficient sphincter mechanism and rectal hypocompliance/hypersensitivity, standard management is problematic, as correction of the sphincter defect may not abolish faecal urgency, which may be incapacitating. This has been achieved by rectal augmentation with a distal ileal segment, and is associated with normalization of rectal sensory thresholds and frequency of high-amplitude rectal contractions.10 We accept with time a greater understanding of the pathophysiological mechanisms associated with incontinence may unveil further targets for symptomatic relief, but feel that recently published work has already revealed exciting avenues for investigation.

Prevalence and Burden of Fecal Incontinence: A Population-Based Study in Women

The epidemiology of fecal incontinence (FI) is incompletely understood. We report the prevalence, clinical spectrum, health care-seeking behavior, and quality of life (QOL) in community women with FI. A questionnaire was mailed to an age-stratified random sample of 5300 Olmsted County, Minnesota, women identified by the Rochester Epidemiology Project. Symptom severity was assessed by a validated scale, and impact on QOL was evaluated for subjects who had any FI during the past year. The prevalence of FI was calculated with direct age adjustment to the 2000 US white female population. Altogether, 2800 of 5300 women (53%) responded to the survey. The overall age-adjusted prevalence of FI in the past year was 12.1 per 100 (95% confidence interval, 11.0-13.1). The prevalence increased with age from 7 (third decade) to 22 (sixth decade) per 100 and was steady thereafter. Symptoms were mild (45%), moderate (50%), or severe (5%), and symptom severity was related to the impact of FI on QOL and physician-consulting behavior. Moderate to severe impact on >/=1 domain of QOL was reported by 6% with mild, 35% with moderate, and 82% with severe symptoms, whereas 5% with mild, 10% with moderate, and 48% with severe FI had consulted a physician for FI in the past year. More than 1 of 10 adult women in the population have FI; almost 1 of 15 have moderate to severe FI. FI significantly impacts QOL and prompts health care utilization predominantly in women with moderate to severe symptoms.

Results and Complications after Ileal Pouch Anal Anastomosis: A Meta-Analysis of 43 Observational Studies Comprising 9,317 Patients

Objective: To analyze the literature of ileal pouch anal anastomosis (IPAA) regarding complications and functional outcome, to provide audit data for individual surgeons and units to assess their own performance against and also to serve as reference standard for the assessment of novel alternatives. Background: IPAA is the standard restorative procedure for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). This operation is, however, associated with distinct rates of failure, complications and fecal incontinence. Methods: A meta-analysis on pooled incidences of complications of IPAA was conducted. Medline search and cross-reference search identified studies on IPAA (n ≧ 50). Two authors independently performed the data extraction on study characteristics, diagnosis, type of operation, pouch-related complications, pouch failure and functional results. In case of disagreement consensus was reached by joint review of the study. Estimates of pouch-related complications, pouch failure and functional results are described as pooled percentages with 95% confidence interval. Results: The initial search based on 1,206 abstracts yielded 43 studies eligible for further analysis. Indications for IPAA were UC in 87.5%, FAP in 8.9% and other diagnoses in 3.6%. The median follow-up was 36.7 months. Pouch failure was 6.8%, increasing to 8.5% in case of follow-up of more than 60 months. Pelvic sepsis occurred in 9.5%. Severe, mild and urge fecal incontinence were reported in 3.7, 17, and 7.3%, respectively.No effect of experience, duration of follow-up and type of surgical technique on the incidence of pouch failure and pelvic sepsis was demonstrable. Conclusions: Current techniques for restorative surgery after proctocolectomy are associated with non-negligible complication rates and leave room for improvement and continuation of development of alternative procedures.

Rectal Hypersensitivity Worsens Stool Frequency, Urgency, and Lifestyle in Patients With Urge Fecal Incontinence

Rectal sensory mechanisms are important in the maintenance of fecal continence. Approximately 50 percent of patients with urge incontinence have lowered rectal sensory threshold volumes (rectal hypersensitivity) on balloon distention. Rectal hypersensitivity may underlie the heightened perception of rectal filling; however, its impact on fecal urgency and incontinence is unknown. This study was designed to investigate the impact of rectal hypersensitivity in patients with urge fecal incontinence. Prospective and retrospective audit review of all patients (n = 258) with an intact native rectum referred to a tertiary colorectal surgical center for physiologic investigation of urge fecal incontinence during a 7.5-year period. Patients with urge fecal incontinence who had undergone pelvic radiotherapy (n = 9) or rectal prolapse (n = 6) were excluded. A total of 108 of 243 patients (44 percent) were found to have rectal hypersensitivity. The incidence of anal sphincter dysfunction was equal (90 percent) among those with or without rectal hypersensitivity. Patients with urge fecal incontinence and rectal hypersensitivity had increased stool frequency (P < 0.0001), reported greater use of pads (P = 0.003), and lifestyle restrictions (P = 0.0007) compared with those with normal rectal sensation, but had similar frequencies of incontinent episodes. Urge fecal incontinence relates primarily to external anal sphincter dysfunction, but in patients with urge fecal incontinence, rectal hypersensitivity exacerbates fecal urgency, and this should be considered in the management and surgical decision in patients who present with fecal incontinence.

Diagnostic Evaluation of Patients with Faecal Incontinence at a Specialist Institution

Background: Evaluation of the anorectal function, clinically, structurally, and functionally, in patients with faecal incontinence should ensure appropriate and individual treatment. Methods: Two hundred and twenty-six patients with faecal incontinence were reviewed regarding disease history and results of anorectal physiological tests and anal ultrasonography. Results: The mean age was 54 years, and 191 patients (85%) were female. Sixty-two patients had passive faecal incontinence only, 49 had urge faecal incontinence only, and 115 had both passive and urge faecal incontinence. Patients with passive faecal incontinence only had a significantly higher voluntary contraction pressure and less external sphincter abnormalities than patients with urge faecal incontinence or both passive and urge faecal incontinence. The structural abnormalities of the internal and external anal sphincters identified on anal ultrasonography were significantly associated with a low maximum resting pressure and with a low voluntary contraction pressure, respectively. The causes identified for this faecal incontinence were: in 90 patients idiopathic, in 76 obstetric injury, in 36 internal anal sphincter degeneration, in 20 anal surgical injury, in 6 rectal prolapse, and in 9 patients miscellaneous. Conclusions: The anal sphincter structure as demonstrated by ultrasonography was closely related to the anorectal function, as determined by anorectal physiological tests, and the observations from these were reflected in the range of patient-reported symptoms. Anal ultrasonography and anorectal physiological tests are useful tools, enabling us to identify the mechanisms and causes of faecal incontinence in at least 60% of the patients.

Sacral neuromodulation: new applications in the treatment of female pelvic floor dysfunction.

The first sacral nerve stimulators implanted by Tanagho and Schmidt (1981) were performed for the indications of urinary urge incontinence, urgency-frequency, and nonobstructive urinary retention. Since that time, observations have been made for benefits beyond voiding disorders. These additional benefits have included re-establishment of pelvic floor muscle awareness, resolution of pelvic floor muscle tension and pain, decrease in vestibulitis and vulvadynia, decrease in bladder pain (interstitial cystitis), and normalization of bowel function. Therapy for fecal incontinence in patients with a structurally intact sphincter mechanism appears to be very promising. Investigators agree that there is a role for sacral nerve stimulation in patients with urge fecal incontinence that have failed conservative efforts. Objective manovolumetric testing shows an increase in resting pressure, an increase in voluntary contraction pressure, a decrease in rectal volumes which cause first urge, a decrease in rectal volume to initiate first urge to defecate, and an increase in duration of maximum squeeze pressure. Intractable interstitial cystitis is defined as patients that have failed conventional therapy. Historically, the only option remaining was extirpative surgery or diversion. Maher et al. reported on patients with intractable interstitial cystitis who had undergone sacral nerve stimulation. They found that 73% of these patients had a reduction in pelvic pain, daytime frequency, nocturnal urgency and an increase in average voided volumes. The final area of interest concerns refractory pelvic pain. Siegal et al. reported a decrease in severity, number of hours of pain, and improved quality of life measures in patients who underwent transforamenal sacral nerve stimulations. These patients had all failed conventional pain therapy. While the data are encouraging in these new arenas of pelvic floor disorders, investigators acknowledge the need for multicenter, statistically powered studies to evaluate the validity of these findings.

Female pelvic floor dysfunction and estrogen therapy

Female pelvic floor dysfunction may present as urinary incontinence, uterovaginal prolapse, or rectal incontinence or prolapse. Epidemiological studies for urinary incontinence show a prevalence of between 10 and 40% of the adult female population. The incidence of uterovaginal prolapse and fecal incontinence in women presenting with urinary incontinence is 40% and 20%, respectively. MacLennan and colleagues, in a cross-sectional population prevalence survey of 1546 interviewed women aged 15‐ 97 years, found that 46% were experiencing pelvic floor dysfunction defined as stress or urge incontinence, flatus or fecal incontinence, current symptoms of vaginal prolapse or previous pelvic floor repair 1 . Pelvic floor dysfunction was associated with significant physical and mental distress upon quality-of-life assessment and was described by the authors as an epidemic. In a study by Samsioe 2 , one in three women between 55 and 75 years of age had urogenital symptoms, with 58% seeking medical help and 11% taking medications for these symptoms. Pelvic floor dysfunction is therefore a common cause of morbidity and suffering in women, so any effective preventive or therapeutic measures will make a significant contribution to improving women’ s health generally. Pelvic floor dysfunction has a multifactorial etiology, with suggested causes being pregnancy and delivery, obesity, medications, pelvic surgery, neurological impairment, excessive heavy lifting or straining, and defective collagen. The role of the menopause and estrogen loss in causation is controversial, as even good prospective epidemiological studies have difficulty in separating the importance of the various confounding etiological factors, particularly aging and the menopause. As women age, they are more likely to be more overweight, be taking medications, have pelvic surgery and be menopausal. Urinary symptoms including incontinence and uterovaginal prolapse are common in women, and increase in the 40‐ 60-year-old. Estrogen and progesterone receptors are present in the urethra, bladder, vagina and pelvic floor. Menopausal loss of estrogen results in atrophy of the urogenital tract and connective tissue changes. Some of these can be prevented or reversed by estrogen supplementation. Clinicians frequently prescribe estrogens orally, transdermally or transvaginally for urinary symptoms of frequency, urgency and urge incontinence in postmenopausal women, sometimes with short-term clinical effect 3 . Drug trials have shown a high placebo effect in women with urge symptoms. This may in part be due to the bladderretraining effect of the use of the urinary diary in assessment. The real long-term clinical benefit of estrogens for these symptoms needs further clarification. Meta-analysis of randomized trials has shown no significant improvement in urinary incontinence with estrogens, compared with placebo 4 , although most trials have been small and of short duration. The Heart and Estrogen/ progestin Replacement Study (HERS) was a 4-year randomized trial to evaluate estrogen plus progestin therapy for the prevention of coronary heart disease in high-risk patients. In this study 5 , 1525 women (55%) reported at least one episode of urinary incontinence each week, and were randomly assigned to oral conjugated estrogen (0.625 mg) plus medroxyprogesterone acetate (2.5 mg) or placebo daily and followed for

Long-Term Results of Overlapping Anterior Anal-Sphincter Repair for Obstetric Trauma

Summary Background Anterior structural damage to the anal sphincter occurs in up to a third of women at first vaginal delivery, and of these a third have new bowel symptoms. The standard treatment for such structural damage is anterior overlapping anal-sphincter repair. We aimed to assess the long-term results of this operation. Methods We assessed the long-term results in 55 consecutive patients who had had repair a minimum of 5 years (median 77 months [range 60–96]) previously. Questionnaire and telephone interview assessed current bowel function and continence, restriction in activities related to bowel control, and overall satisfaction with the results of surgery. 42 of these patients had been continent of solid and liquid stool at a median of 15 months after the repair. Findings We were able to contact 47 (86%) of the 55 patients. One of these patients had required a proctectomy and end ileostomy for Crohn's disease. Of the remaining 46 patients, 27 reported improved bowel control without the need for further surgery, and 23 rated their symptom improvement as 50% or greater. Seven patients had undergone further surgery for incontinence and one patient had not had a covering stoma closed. Thus, the long-term functional outcome of the sphincter repair alone could be assessed in 38 patients. Of these patients, none was fully continent to both stool and flatus; only four were totally continent to solid and liquid stool; six had no faecal urgency; and eight had no passive soiling. Of the 38 patients, 20 still wore a pad for incontinence and 25 reported lifestyle restriction. 14 reported the onset of a new evacuation disorder after sphincter repair. 23 of the 46 patients contacted had a successful long-term outcome (defined as no further surgery and urge faecal incontinence monthly or less). Interpretation The results of overlapping sphincter repair for obstetric anal-sphincter damage seem to deteriorate with time. Preoperative counselling should emphasise that although most patients will improve after the procedure, continence is rarely perfect, many have residual symptoms, and some may develop new evacuation disorders.

Long-term results of overlapping anterior anal-sphincter repair for obstetric trauma

Anterior structural damage to the anal sphincter occurs in up to a third of women at first vaginal delivery, and of these a third have new bowel symptoms. The standard treatment for such structural damage is anterior overlapping anal-sphincter repair. We aimed to assess the long-term results of this operation. We assessed the long-term results in 55 consecutive patients who had had repair a minimum of 5 years (median 77 months [range 60-96]) previously. Questionnaire and telephone interview assessed current bowel function and continence, restriction in activities related to bowel control, and overall satisfaction with the results of surgery. 42 of these patients had been continent of solid and liquid stool at a median of 15 months after the repair. We were able to contact 47 (86%) of the 55 patients. One of these patients had required a proctectomy and end ileostomy for Crohn's disease. Of the remaining 46 patients, 27 reported improved bowel control without the need for further surgery, and 23 rated their symptom improvement as 50% or greater. Seven patients had undergone further surgery for incontinence and one patient had not had a covering stoma closed. Thus, the long-term functional outcome of the sphincter repair alone could be assessed in 38 patients. Of these patients, none was fully continent to both stool and flatus; only four were totally continent to solid and liquid stool; six had no faecal urgency; and eight had no passive soiling. Of the 38 patients, 20 still wore a pad for incontinence and 25 reported lifestyle restriction. 14 reported the onset of a new evacuation disorder after sphincter repair. 23 of the 46 patients contacted had a successful long-term outcome (defined as no further surgery and urge faecal incontinence monthly or less). The results of overlapping sphincter repair for obstetric anal-sphincter damage seem to deteriorate with time. Preoperative counselling should emphasise that although most patients will improve after the procedure, continence is rarely perfect, many have residual symptoms, and some may develop new evacuation disorders.

Biofeedback training in patients with fecal incontinence

This study was undertaken to assess the functional results of biofeedback training in patients with fecal incontinence in relation to clinical presentation and anorectal manometry results. Twenty-six consecutive patients with fecal incontinence were treated with biofeedback training using anorectal manometry pressure for visual feedback. Ten patients had passive incontinence only, six patients had urge incontinence, and ten patients had combined passive and urge incontinence. Patients with urge incontinence had a lower maximum voluntary contraction pressure (92+/-12 mmHg) and a lower maximum tolerable volume (78+/-13 ml) than patients with passive incontinence (140+/-43 mmHg and 166+/-73 ml). Twenty-two patients completed the treatment, five patients (23 percent) showed excellent improvement, nine patients (41 percent) had good results, and eight (36 percent) patients showed no improvement. At follow-up on average of 21 months after therapy, 41 percent of our patients reported continued improvement. The maximum tolerable volume was higher in those with excellent (140.4+/-6.8 ml) or good (156.3+/-6.64 ml) results of therapy than it was in those with poor results (88.5+/-2.5 ml). Greater asymmetry of the anal sphincter also correlated to poor results. Biofeedback therapy improved continence immediately after training and at follow-up after 21 months, but the initial results were better. The urge fecal incontinence seems to be related to function of the external anal sphincter and to the maximum tolerable volume. Low maximum tolerable volume and anal sphincter asymmetry were associated with a poor outcome of therapy.

Perineal examination as a predictor of underlying external anal sphincter damage.

To assess the relation between perineal inspection and sphincter integrity in parous women. Prospective observational study. District general hospital. Fifty-seven consecutive parous women attending a gynaecology clinic for problems unrelated to the pelvic floor. A detailed history of bowel function and mode of delivery obtained; the perineum inspected to determine the presence and position of scarring, and anal endosonography performed. In 19 women with an intact perineum on inspection, endosonography showed perineal scarring in five, with both perineal and sphincter scarring in three. Four had urge faecal incontinence. Three patients had a perineal tear only on inspection, but this group was too small for analysis and was discounted. Nine had an episiotomy scar only. Endosonography demonstrated perineal scarring in four, and combined perineal and sphincter scarring in two; one woman in this group had urge faecal incontinence. Twenty-six women had episiotomy and perineal tears on inspection. Endosonography revealed underlying perineal scarring in five women, with combined perineal and sphincter scarring in 14; six women in this group had urge faecal incontinence and one passive incontinence for flatus. Sonographically the scarring was anterior and circumferential rather than radial, and mostly left-sided, whereas on inspection episiotomy and perineal scarring were right sided. A normal perineum on clinical examination does not exclude underlying sphincter damage. The incidence of sphincter damage increases significantly when an episiotomy scar is associated with a perineal tear.

Primary degeneration of the internal anal sphincter as a cause of passive faecal incontinence

Faecal incontinence is usually attributed to pelvic-floor denervation of striated muscle or direct sphincter trauma. We have identified a cause of passive faecal incontinence related to degeneration of the internal anal sphincter smooth muscle, in the absence of denervation, structural damage, external-sphincter weakness, or sensory abnormalities. Patients were included on the basis of: passive faecal incontinence, no urge faecal incontinence, low anal pressure whilst at rest, normal anal-squeeze pressure, endosonographically confirmed circumferentially intact internal and external anal sphincters, and normal pudendal nerve terminal nerve latencies. In a second analysis done to assess the proportion of patients with this disorder, we recorded the cause of incontinence in consecutive patients seen during a 6-month period. 45 patients (35 women, median age 63 years, range 23-80 years) fulfilled the diagnostic criteria. Median duration of symptoms was 2 years (3 months to 20 years). Nine of the 35 women were nulliparous. The median resting anal pressure was 40 cm water (16-56 cm water, normal > 60 cm water). Endosonography revealed an internal sphincter that was thin and hyperechogenic, and had a poorly defined edge. The normal increase in the thickness of the internal anal sphincter with age was not seen. Anal-squeeze pressure, sensitivity, and pudendal nerve latencies were normal. In the second analysis the condition was identified in eight of 230 patients, representing 4% of new referrals. Primary degeneration of the internal anal sphincter smooth muscle is a discrete clinical condition causing passive faecal incontinence.