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Contents
19 Gut Microbiota Characterization in Fecal
Incontinence and Irritable Bowel Syndrome . . . . . . . . . . . . . . . . . . . . . 163
Giovanni Marasco, Vincenzo Stanghellini, Giovanni Barbara,
and Cesare Cremon
20 Low Anterior Resection Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Mario Morino and Antonella Nicotera
21 Incontinence-Associated Dermatitis: An
Insidious and Painful Condition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Graziella Babino and Giuseppe Argenziano
22 Perineal Descent and Incontinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
Adolfo Renzi and Antonio Brillantino
23 Reconstruction of Wide Anal Sphincter Defects by
Crossing Flaps of Puborectalis Muscle . . . . . . . . . . . . . . . . . . . . . . . . . . 197
Antonio Longo
24 Treatment Cost Reimbursement in Italy . . . . . . . . . . . . . . . . . . . . . . . . 205
Vincenzo Landol and Adriana Maria Landol
xi
Part I
Overview
History ofAnal Incontinence
anditsTreatments
CorradoRispoli andGennaroRispoli
1.1 History ofAnal Incontinence
All animals with a digestive system and an anus are generally provided with a
sphincter system (a circular muscular structure) that creates rhythmicity in the
expulsion of feces. Both humans and higher animals regulate defecation with a
continence mechanism. The peristalsis that moves the feces down to the rectum is
not controlled by will but by the vegetative nervous system, and therefore the only
way in which animals regulate the elimination of feces is by retaining them with the
mechanism of continence. In animals, continence is relevant for social interactions:
with the deposition of excrement in specic places, some animals mark their territory or demonstrate their fertility. For that purpose many animals use their legs and
tails to scatter droppings at a distance and thus cover wider areas.
In humans, continence is naturally acquired after some time (usually 3–4years)
but becomes important with the beginning of social life; it is necessary to separate
this act from other people, not out of modesty (which will appear only centuries
later), but for the management of excrement.
As evidenced by many archaeological ndings, the Romans had collective
latrines where they used to have discussions while defecating (Fig.1.1).
Whereas the rst description of urine incontinence dates back to 1500B.C. (Ebers
Papyrus), no data are available regarding the rst description of fecal incontinence
in ancient times [1]. Its rst description was as a symptom of rectal prolapse.
Andreas Vesalius performed dissections on cadavers and described the colon,
rectum and anus in meticulous detail, as illustrated in his De Humani Corporis
1
C. Rispoli (*)
General Surgery Unit, Monaldi Hospital, Naples, Italy
e-mail: dott.rispoli@gmail.com
G. Rispoli
Museo delle Arti Sanitarie, Naples, Italy
e-mail: info@ilfarodippocrate.it
© The Author(s) 2023
L. Docimo, L. Brusciano (eds.), Anal Incontinence, Updates in Surgery,
https://doi.org/10.1007/978-3-031-08392-1_1
3
4
Fig. 1.1 The communal Roman latrine at Ostia, Italy (Photo by Carole Raddato, reproduced
under CC-BY-SA license from https://www.ickr.com/photos/carolemage/6681231029/in/
photostream/)
C. Rispoli and G. Rispoli
Fig. 1.2 Leonardo da
Vinci’s representation of
the anal sphincter in
relaxed (left) and
contracted (right) position
(details redrawn from
Leonardo’s original
drawing, by courtesy of
Roberto Toderico)
Fabrica, published in 1543. The anal sphincters as well as the levator ani muscle
were clearly described by the author. However, the rst illustration of the anal
sphincter can be found in Leonardo da Vinci’s anatomical drawing of the rectum
from the fteenth century. This drawing depicts the anal sphincter as a ower with
ve different petal-shaped muscular structures and is accompanied by a theory on
its functioning (Fig.1.2). The ve-petal structure may derive from the hemorrhoids:
three major and two minor.
1 History ofAnal Incontinence andits Treatments
No detailed information on physiology was known at that time. Nevertheless, the
risks and consequences of vaginal delivery on fecal incontinence were already
known in Rome in the second century A.D. but repair of the injured anal canal was
not described by the Romans [2].
Until the eighteenth century, the theory that explained continence was entirely
based on the muscular layer of the rectum which pushed the feces outside the anus
(Jean Astruc).
In 1835, Daniel Oliver wrote his First Lines of Physiology in which he stated that
“the concurrence of the voluntary muscles with the action of the intestine itself, is
indispensable to overcome the contraction of the sphincter of the rectum”, designing the rst scientic theory [3]. The theory of a rectal “reservoir” and a muscular
sphincter complex was then rened and improved in the twentieth century by two
great scientists of the colon and rectum: Alan Park and Ahmed Shak [4, 5]. Their
vision of the anatomy and physiology of the rectum and anus are still a key element
of today’s theories.
5
1.2 History ofTreatments forAnal Incontinence
1.2.1 Colonic Irrigation andColostomy
Colonic irrigation was the rst treatment described for anal incontinence although
this was not its proper and exclusive indication; already in the fth century B.C. the
Egyptians “cleansed” themselves on three consecutive days every month, by using
enemas to purify their body, as reported by Herodotus. This technique was also
recorded in the Babylonian and Assyrian tables and in Hindu medicine. Though
widely used through the centuries, no data were reported on the outcomes of colonic
irrigation until the modern era.
The rst surgical treatment for anal incontinence was stoma creation (rst performed in 1776 by Pillore [6]); as in the case of colonic irrigation, this technique
was mainly adopted for conditions other than incontinence.
1.2.2 Anal Sphincter Repair
The rst description of a successful sphincter repair dates back to 1882; Warren
performed a vaginal mucosal ap to protect the repair of the lacerated rectum and
anus [7]. This technique was also reported by other authors in case series showing
good results in the short-term follow-up [8].
Many techniques for the correction of incontinence caused by sphincter damage
were subsequently developed by different surgical teams [9], but all of them were based
mainly on end-to-end sphincter repair, which often had high failure rates [10, 11]. The
rst modern technique, overlapping sphincteroplasty, was developed in 1973 as an
improvement of end-to-end repair. This technique is still performed with excellent
results [12] and is also reported in the guidelines as a standard surgical treatment [13].
6
C. Rispoli and G. Rispoli
As regards “idiopathic” incontinence, however, it was not until 1975 that the rst
surgical technique was reported. That year, Sir Alan Parks described the so-called
“postanal repair”, a technique aiming to increase the length of the anal canal, restore
the anorectal angle, and create a ap valve mechanism. The promising short-term
results of this technique were less favorable in the long-term follow-up, mainly
because of misdetection of subclinical anterior sphincter defect after delivery [14].
In 1991, the introduction of endoanal ultrasound led to a dramatic change of
view regarding the etiology of anal incontinence [15], and many cases of idiopathic
incontinence could now be labelled as delivery sphincter damage and properly
repaired with overlapping sphincteroplasty [16]. Postanal repair is now conned to
a small minority of patients with anal incontinence and most of the international
guidelines do not recommend it.
1.2.3 Muscle Transposition andArtificial Sphincter
Muscle transposition techniques mainly derived from the rst experience with muscle ber transposition for ocular palsy (1908, Hummelsheim) [17]. In the rst half
of the twentieth century, the idea of transposing muscle bers or fascia to reinforce
a weakened or damaged sphincter was developed. The rst techniques based on anal
encirclement by fascia date back to Harvey Stone in 1932 [18, 19] and were later
modied in 1941 [20]; the results were promising, with a reported success rate of
70%. Other authors chose to suture together muscle bers from both gluteal muscles anterior to the rectum, thus suspending it in a kind of muscular “hammock” [21,
22]. Merging these approaches, in 1952 Pickrell codied his “gracilis muscle trans-
plant” that was later to take his name [23]. This technique is now performed with an
implantable electrical pulse generator (stimulated muscle transposition) and will be
discussed later in this book.
The rst articial sphincter for human use was developed for the treatment of
urinary incontinence in 1973 by American Medical Systems (AMS, Minnetonka,
MN, USA) and was later applied to anal incontinence by Christiansen and Lorentzen
in 1987 [24]. New specic devices have been developed since then but, considering
their recent introduction, they will be thoroughly discussed in another chapter of
this book.
1.2.4 Bulking Agents
Like all innovators, Ahmed Shak not only developed a theory of the mechanism of
anal continence but also proposed a new kind of treatment option: the use of bulking
agents. In 1993 he published a case series on polytetrauoroethylene injection for
the treatment of partial fecal incontinence [25], with no complications reported and
with promising results (improvement or cure in all cases). This technique was then
reproduced with the aid of endoanal ultrasound to improve proper positioning of the
agent, and now all bulking agents require ultrasound-guided positioning.
1 History ofAnal Incontinence andits Treatments
7
New technologies and new materials developed during the last twenty years have
expanded this eld of incontinence treatment with continuous news from scientic
research. On the other hand, this fragmentation of materials and techniques has
made it difcult to compare the results achieved with bulking agents and therefore
the evidence to support their use has remained scarce.
1.2.5 Other Treatments andTechniques
Many other invasive and noninvasive treatments are now available for anal incontinence (sacral nerve stimulation, biofeedback, etc.) but, because their development
is recent, they will be discussed in a separate chapter.
References
1. Ebbell B. The Papyrus Ebers: the greatest Egyptian medical document. Copenhagen: Ejnar
Munksgaard; 1937.
2. Briel JW.Treatment of fecal incontinence. Ridderkerk: Ridderprint BV; 2000. p.11.
3. Oliver D.First lines of physiology. Boston: Marsh. James Munroe: Capen & Lyon; 1835.
4. Parks AG, Rob C, Smith R, Morgan CN.Clinical Surgery: Abdomen and rectum and anus.
London: Butterworths; 1966.
5. Shak A.A new concept of the anatomy of the anal sphincter mechanism and the physiology of
defecation. The external anal sphincter: a triple-loop system. Investig Urol. 1975;12(5):412–9.
6. Hardy KJ.Surgical history. Evolution of the stoma. Aust N Z J Surg. 1989;59(1):71–7.
7. Warren JC.A new method of operation for the relief of rupture of the perineum through the
sphincter and rectum. Trans Am Gynecol Soc. 1882;7:322–30.
8. Block IR, Rodriguez S, Olivares AL.The Warren operation for anal incontinence caused by
disruption of the anterior segment of the anal sphincter, perineal body, and rectovaginal septum: report of ve cases. Dis Colon Rectum. 1975;18(1):28–34.
9. Sistrunk WE.Contribution to plastic surgery: an open operation for extensive laceration of the
anal sphincter. Ann Surg. 1927;85(2):185–93.
10. Lockhart-Mummery JP.Diseases of the rectum & colon and their surgical treatment. Toronto:
Macmillan; 1923.
11. Blaisdell PC.Repair of the incontinent sphincter ani. Am J Surg. 1957;94(4):573–6.
12. Goetz LH, Lowry AC.Overlapping sphincteroplasty: is it the standard of care? Clin Colon
Rectal Surg. 2005;18(1):22–31.
13. Paquette IM, Varma MG, Kaiser AM, et al. The American Society of Colon and Rectal
Surgeons’ clinical practice guideline for the treatment of fecal incontinence. Dis Colon
Rectum. 2015;58:623–36.
14. Surgical management of faecal incontinence in: Madoff RD, Pemberton JH, Mimura T,
Laurberg S, editors. Faecal incontinence: the management of faecal incontinence in adults
(NICE Clinical Guidelines, No 49). London: National Collaborating Centre for Acute Care;
2007. https://www.nice.org.uk/guidance/cg49. Accessed 28 Nov 2021.
15. Burnett SJD, Speakman CTM, Kamm MA, Bartram CI. Conrmation of endosonographic
detection of external anal sphincter defects by simultaneous electromyographic mapping. Br
J Surg. 1991;78(4):448–50.
16. Abrams P, Andersson KE, Birder L, etal. Fourth International Consultation on Incontinence
Recommendations of the International Scientic Committee: Evaluation and treatment
8
of urinary incontinence, pelvic organ prolapse, and fecal incontinence. Neurourol Urodyn.
2010;29(1):213–40.
17. Baker DC, Conley J.Regional muscle transposition for rehabilitation of the paralyzed face.
Clin Plast Surg. 1979;6(3):317–31.
18. Stone HB.Plastic operation for anal incontinence. Tr South Surg Assoc. 1926;41:235–40.
19. Stone HB.Plastic operation for anal incontinence. Further report. Arch Surg. 1932;24:120–5.
20. Stone HB, McLanahan S.Results with the fascia plastic operation for anal incontinence. Ann
Surg. 1941;114(1):73–7.
21. Chittenden AS.Reconstruction of anal sphincter by muscle slips from the glutei. Ann Surg.
1930;92(1):152–4.
22. Biström O.Plastischer Ersatz des M.Sphincter ani. Acta Chir Scand. 1944;90:431–48.
23. Pickrell KL, Broadbent TR, Masters FW, Metzger JT.Construction of a rectal sphincter and
restoration of anal continence by transplanting the gracilis muscle; a report of four cases in
children. An Surg. 1952;135(6):853–62.
24. Christiansen J, Lorentzen M.Implantation of articial sphincter for anal incontinence. Lancet.
1987;330(8553):244–5.
25. Shak A.Polytetrauoroethylene injection for the treatment of partial fecal incontinence. Int
Surg. 1993;78(2):159–61.
C. Rispoli and G. Rispoli
Open Access This chapter is licensed under the terms of the Creative Commons Attribution-
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the copyright holder.
Epidemiology, Anorectal Anatomy,
Physiology andPathophysiology
ofContinence
GaetanoGallo, AlbertoRealis Luc, andMarioTrompetto
2.1 Introduction andEpidemiology
Continence can be dened as the ability to retain atus, liquid, or solid stools during
normal daily life, including while physically exercising, coughing, sneezing, and
changing position [1].
The anal canal is normally closed at rest and during sleep due to the steady activity of the internal anal sphincter (IAS) supported by the tonic activity of the external
anal sphincter (EAS) and puborectalis.
The integrity of the continence and defecation mechanism is a multifactorial
process that involves somatic and visceral functions and allows postponing defecation when necessary and avoiding the uncontrolled passage of feces or gas, causing
patients to feel embarrassed with a negative impact on lifestyle, work, and interpersonal relationships [2].
Considering the heterogeneity of the problem, the incidence and prevalence of
fecal incontinence (FI) are difcult to establish because they depend on the type and
frequency of incontinence, age, and gender (Table2.1) [3]. In fact, if the leading
cause in women is post-obstetric injury, in men and the elderly, other factors such as
anorectal surgery and diabetes mellitus must be considered [4, 5]. Moreover, the use
of many terms to dene FI has generated confusion and favored this trend.
Several authors have tried to quantify this phenomenon without achieving a
denitive percentage [6–8]. According to Sharma etal. [6], the prevalence of FI
ranges between 1.4% and 19.5%, whereas in the systematic review by Ng etal. [7]
it has a median prevalence of 7.7%, without any difference between genders, but
with a greater percentage in people older than 90 (15.9% vs. 5.7%) compared with
people 15–34years old.
2
G. Gallo (*) · A. Realis Luc · M. Trompetto
Department of Colorectal Surgery, S.Rita Clinic, Vercelli, Italy
e-mail: dr.gaetanogallo@libero.it; alberto.realisluc@libero.it; trompetto.mario@libero.it
© The Author(s) 2023
L. Docimo, L. Brusciano (eds.), Anal Incontinence, Updates in Surgery,
https://doi.org/10.1007/978-3-031-08392-1_2
9
10
G. Gallo et al.
Table 2.1
Structure
Anal sphincter
muscle
Rectum Inammation, IBD, radiation, prolapse,
Puborectalis
muscle
Pudendal nerve Obstetrical/surgical injury
CNS, spinal cord,
ANS
Function
Anorectal
sensation
Fecal impaction Dyssynergic defecation Loss of stool awareness
Stool characteristics
Volume and
consistency
Irritants Bile salt malabsorption, laxatives Diarrhea
Hard stools/
retention
Miscellaneous
Physical mobility/
cognitive function
Psychosis Willful soiling Multifactorial changes
Drugs Anticholinergics
Food intolerance Lactose/fructose/sorbitol Diarrhea/atus
IBD, inammatory bowel disease; IBS, irritable bowel syndrome; CNS, central nervous system;
ANS, autonomic nervous system
Reproduced from [3] with permission from Elsevier
Pathophysiological mechanisms leading to fecal incontinence
Obstetric injury
Hemorrhoidectomy, anal dilatation,
secondary to neuropathy
aging, IBS
Excessive perineal descent, aging,
trauma
Excessive straining/perineal descent
Spinal cord injury, head injury, back
surgery, multiple sclerosis, diabetes,
stroke, avulsion injury
Obstetrical, CNS, ANS injury Loss of stool awareness
Infection, IBD, IBS, drugs, metabolic Diarrhea and urgency
Dyssynergia/drugs Fecal retention with overow
Aging, dementia, disability Multifactorial changes
Laxatives
Antidepressants
Caffeine/muscle relaxants
Sphincter weakness
Loss of sampling reex
Sphincter weakness
Loss of sampling reex
Obtuse anorectal angle
Sphincter weakness
Sphincter weakness
Sensory loss, impaired reexes
Loss of sensation, impaired
reexes, secondary myopathy,
loss of accommodation
Rectoanal agnosia
Rectoanal agnosia
Rapid stool transport
Impaired accommodation
Constipation
Diarrhea
Alter sensation/constipation
Relaxes sphincter tone
Malabsorption
The higher prevalence among the elderly may be due to the physiological effects
of aging on continence, such as impaired rectal sensation or dysfunction of both the
IAS and EAS, which become thicker [9], as well as polypharmacy. In fact, the abuse
of laxatives taken to avoid fecal impaction or constipation can exacerbate the condition. In this context, the highest prevalence currently recorded is among nursing
home residents, where involvement reaches up to 50% [10].
The difculty in establishing the extent of FI could be due to embarrassment in
reporting the symptoms, as occurs with other proctological diseases [11]. Brown
etal. [12], in an internet-based questionnaire study of 5817 women, showed that
one-fth of women over 45in the USA suffer from at least one episode of FI per
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