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Updates in Surgery
Ludovico Docimo
Luigi Brusciano Editors
Anal
Incontinence
Clinical Management and
Surgical Techniques
Updates in Surgery
The aim of this series is to provide informative updates on hot topics in the areas of
breast, endocrine, and abdominal surgery, surgical oncology, and coloproctology,
and on new surgical techniques such as robotic surgery, laparoscopy, and minimally
invasive surgery. Readers will nd detailed guidance on patient selection,
performance of surgical procedures, and avoidance of complications. In addition, a
range of other important aspects are covered, from the role of new imaging tools to
the use of combined treatments and postoperative care.
The topics addressed by volumes in the series Updates in Surgery have been
selected for their broad signicance in collaboration with the Italian Society of
Surgery. Each volume will assist surgical residents and fellows and practicing
surgeons in reaching appropriate treatment decisions and achieving optimal
outcomes. The series will also be highly relevant for surgical researchers.
More information about this series at https://link.springer.com/bookseries/8147
Ludovico Docimo • Luigi Brusciano
Editors
Anal Incontinence
Clinical Management and
Surgical Techniques
Editors
Ludovico Docimo
Division of General, Mini-invasive
Oncological, and Bariatric Surgery
University of Campania Luigi Vanvitelli
Naples, Italy
Luigi Brusciano
Division of General, Mini-invasive
Oncological, and Bariatric Surgery
University of Campania Luigi Vanvitelli
Naples, Italy
This book is an open access publication.
The publication and the distribution of this volume have been supported by the Italian Society
of Surgery.
ISSN 2280-9848 ISSN 2281-0854 (electronic)
Updates in Surgery
ISBN 978-3-031-08391-4 ISBN 978-3-031-08392-1 (eBook)
https://doi.org/10.1007/978-3-031-08392-1
© The Editor(s) (if applicable) and The Author(s) 2023
Open Access This book is licensed under the terms of the Creative Commons AttributionNonCommercial- NoDerivatives 4.0 International License (http://creativecommons.org/licenses/by-
nc- nd/4.0/), which permits any noncommercial use, sharing, distribution and reproduction in any medium
or format, as long as you give appropriate credit to the original author(s) and the source, provide a link
to the Creative Commons license and indicate if you modied the licensed material. You do not have
permission under this license to share adapted material derived from this book or parts of it.
The images or other third party material in this book are included in the book’s Creative Commons
license, unless indicated otherwise in a credit line to the material. If material is not included in the book’s
Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the
permitted use, you will need to obtain permission directly from the copyright holder.
This work is subject to copyright. All commercial rights are reserved by the author(s), whether the whole
or part of the material is concerned, specically the rights of translation, reprinting, reuse of illustrations,
recitation, broadcasting, reproduction on microlms or in any other physical way, and transmission or
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license has been granted to the publisher.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specic statement, that such names are exempt from the
relevant protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, expressed or implied, with respect to the material contained herein or for any
errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional
claims in published maps and institutional afliations.
Revision and editing: R.M. Martorelli, Scienzaperta (Novate Milanese, Italy)
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Foreword
Fecal incontinence is still today an important and underestimated disability that
affects a portion of the general population and is caused by many different conditions, including also iatrogenic conditions. The topic is of major interest for surgeons and many different medical specialists because this disease requires a
multidisciplinary approach and an integration of competences.
This volume examines in depth all the pathophysiological aspects of fecal incontinence and the role of surgeons in preventing and treating this complex disease. The
authors are very accurate in clarifying to the reader some nebulous aspects of fecal
incontinence, leaving open, at the same time, some still important questions. All the
recent advancements in the diagnostic owchart, ne differential etiopathogenetic
diagnosis, and tailored choice of therapeutic strategies are, in the present book, well
presented with remarkable illustrations.
All aspects such as treatments, rehabilitation, dietary regimen, social costs, and
even DRG-related issues are very clearly and cleverly addressed, giving this book
the value of an exhaustive guide and very up-to-date reference. For all the abovementioned reasons, I’d like to express my gratitude to Professors Ludovico Docimo
and Luigi Brusciano and to all the authors involved in this work for having successfully completed such a marvelous scientic endeavor, upholding, once again, the
great tradition of Italian Society of Surgery.
Catania, Italy FrancescoBasile
September 2022
Italian Society of Surgery
v
Preface
Although benign, anal incontinence is a highly invalidating condition causing an
important impairment to the patients’ quality of life. Its related social stigma concurs in the underestimation of its prevalence. Nowadays, a high number of patients
still tend to avoid seeking medical care or even talking about the condition, which is
why it is reasonably thought to be more common than known.
Stool consistency, the efciency of the rectum as a reservoir, the sphincter structures, and the innervation of the anatomic area of the perineum are all involved in
the continence process. This book describes the multiple aspects of continence
ranging from anatomical details to recent pathophysiological ndings and nutritional proles. A spotlight has been turned on the innovative and technologic diagnostic tools such as the 3D reconstruction of the whole sphincteric complex using
endoanal ultrasound or the detailed evaluation of sphincter tone utilizing high-resolution manometry. Also addressed are the surgical procedures, from the most common ones performed in every operating room to the more complex approaches
reserved for highly specialized centers and not neglecting the latest surgical options,
such as sphincteroplasty by crossing puborectalis aps.
The several nutritional and rehabilitation proles are also discussed in detail. The
complex interplay of the perineum itself with the diaphragm, the vertebral column,
and the abdominal wall leads to a delicate equilibrium of what has been congured
as the “imaginary cuboid”, whose functional integrity is of utmost importance in the
continence process. This partially explains why assessment of the integrity of the
sphincter structures is not in itself enough to guarantee an appropriate diagnostic
approach to anal incontinence.
A number of physicians with different expertise and specialties have given their
contribution to the topic, providing a comprehensive expert discussion of anal
incontinence that spans from its pathophysiology to the most innovative views on
the diagnostic approach, including the need to analyze physiatric parameters as an
estimate of the wellness of the “imaginary cuboid”. The older and more traditional
treatments are here tightly interwoven with the most recent therapeutic approaches,
vii
viii
Preface
with attention also being paid to the functional treatment of pelvic oor rehabilitation. Objective data supporting the outcomes are also presented so the reader is
provided with a clear and concise review of the literature on the subject.
Naples, Italy LudovicoDocimo
Naples, Italy LuigiBrusciano
September 2022
Contents
Part I Overview
1 History of Anal Incontinence and its Treatments . . . . . . . . . . . . . . . . . . 3
Corrado Rispoli and Gennaro Rispoli
2 Epidemiology, Anorectal Anatomy, Physiology and
Pathophysiology of Continence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Gaetano Gallo, Alberto Realis Luc, and Mario Trompetto
Part II Diagnosis
3 Clinical Evaluation, Etiology, and Classification of
Anal Incontinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Mario Pescatori
4 Neurofunctional Diagnosis and Anorectal Manometry . . . . . . . . . . . . . 29
Filippo Pucciani
5 Role of Ultrasonography for Anal Incontinence . . . . . . . . . . . . . . . . . . 37
Giulio A. Santoro, Patrizia Pelizzo, Ugo Grossi, Rita Cian, Giacomo
Zanus, and Luigi Brusciano
6 Cross-Sectional Imaging in Fecal Incontinence . . . . . . . . . . . . . . . . . . . 49
Alfonso Reginelli, Mariateresa Del Canto, Valentina Caliendo,
Silvia Iovine, Ferdinando Schettino, Fabrizio Urraro,
Salvatore Cappabianca, and Roberto Grassi
Part III Treatment
7 Medical Management and Supportive/Hygienic Measures . . . . . . . . . 63
Roberto Dino Villani and Daniela Di Nicola
8 Diet in Fecal Incontinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Marcellino Monda
ix
x
9 Role of Pelvic Floor Rehabilitation: Patient
Selection and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Ludovico Docimo, Giorgia Gualtieri, Claudio Gambardella,
and Luigi Brusciano
10 Sacral and Percutaneous Tibial Nerve Stimulation,
Stem Cell Therapy, and Transanal Irrigation Device . . . . . . . . . . . . . . 85
Gabriele Naldini, Alessandro Sturiale, Claudia Menconi, Bernardina
Fabiani, Rebecca Aglietti, Lisa Fralleone, Alfredo Annicchiarico,
and Jacopo Martellucci
11 Sphincter Reconstruction: Dynamic Myoplasty,
Artificial Bowel Sphincter, Antegrade Colonic
Enemas and Colostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Francesco Selvaggi, Giacomo Fuschillo, Lucio Selvaggi,
Vinicio Mosca, and Guido Sciaudone
12 Surgical Reconstruction of Traumatic Perineal and
Sphincter Muscle Defects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Bruno Roche and Frédéric Ris
13 Injectable Bulking Agents and SECCA
Radiofrequency Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Carlo Ratto
Contents
14 Implantation of Self-Expandable Solid Prostheses
for Anal Incontinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Ludovico Docimo, Giorgia Gualtieri, Claudio Gambardella, and
Luigi Brusciano
15 When Everything Fails: Prevention and
Therapy of Treatment Failures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Donato F. Altomare, Arcangelo Picciariello, Michele De Fazio,
and Marcella Rinaldi
Part IV Special Considerations and Multidisciplinary Perspectives
16 Cesarean Section Delivery to Prevent Anal Incontinence . . . . . . . . . . . 141
Marco Torella, Marika Pennacchio, and Nicola Colacurci
17 Interrelatedness of Urological Conditions and
Anal Incontinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Ferdinando Fusco, Marco De Sio, Davide Arcaniolo, Celeste
Manfredi, Luigi Napolitano, Simone Morra, and Massimiliano Creta
18 Coexistence of Fecal Incontinence and Constipation. . . . . . . . . . . . . . . 155
Francesco Saverio Mari, Edoardo Maria Muttillo,
and Antonio Brescia
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