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Chapter 36 Pediatric Fecal Incontinence

Treatment

Patients with anorectal malformations with potential

for bowel control and severe constipation as well as

patients with severe idiopathic constipation in whom

dietary measures or gentle laxatives do not work

require a more aggressive regimen. Drugs designed

to increase colon motility are best, as opposed to

medications that are only stool softeners. Softening

the stool without improving colonic motility will

likely make the patient worse, because with soft stool,

patients no longer have control, whereas they do rea-

sonably well with solid stool that allows them to feel

rectal distension.

In many cases, the laxative regimen uses the same

medications that have been tried previously, but the

protocol is different in that the dosage is adapted to

the patient’s response. Response is monitored daily

with an abdominal radiograph, and the laxative dose

is adjusted if necessary. Almost always, the patient

had previously received a lower dose than they need.

Severe constipation is treated as follows:

Disimpaction

The disimpaction process is a vital and often neglect-

ed step. The routine includes administration of ene-

mas three times a day until the patient is disimpact-

ed. This is confirmed radiologically. If the patient

remains impacted after 3 days, then he or she is given

a balanced electrolyte solution via nasogastric tube in

the hospital, and the enema regimen is continued. If

this is unsuccessful, manual disimpaction under

anesthesia may be necessary. It is important to

remember not to prescribe laxatives to a fecally

impacted patient. To do so may provoke vomiting

and crampy abdominal pain. In addition, the patient

will become reluctant to take laxatives because they

are afraid of those symptoms.

Determining Laxative Requirement in a Disimpacted

Patient

Once the patient has been disimpacted, an arbitrary

amount of laxative is started, usually a senna deriva-

tive. The initial amount is based on information the

parent gives about previous response to laxatives and

the subjective evaluation of the megasigmoid on the

contrast enema. The empiric dose is given, and the

patient is observed for the next 24 h. If the patient

does not have a bowel movement in the 24 h after

receiving the laxative, it means the laxative dose was

not enough and must be increased. An enema is also

required to remove the stool produced during the

previous 24 h. Stool in these extremely constipated

patients should never remain in the rectosigmoid for

more than 24 h.

The routine of increasing the amount of laxatives

and giving an enema, if needed, is continued every

night until the child has a voluntary bowel movement

and completely empties the colon. The day that the

patient has a bowel movement (which is usually with

diarrhea), a radiograph should confirm that the

bowel movement was effective, meaning that the

patient completely emptied the rectosigmoid. If the

patient passed stool but did not empty completely,

the laxative dose must be increased.

As this condition covers a wide spectrum, patients

may have laxative requirements much larger than the

manufacturer’s recommendation. Occasionally, in

the process of increasing the amount of laxatives,

patients throw up before reaching any positive effect.

In these patients, a different medication can be tried.

Some patients vomit all types of laxatives and are

unable to reach the amount of laxative that produces

a bowel movement that empties the colon. Such a

patient is considered intractable and therefore a can-

didate for surgical intervention. Most of the time,

however, the dosage that the patient needs in order to

empty the colon completely, as demonstrated radio-

logically, can be achieved. At that dose, the patient

should stop soiling because they are successfully

emptying their colon each day, and because the colon

is empty, they remain clean until the next voluntary

bowel movement.

At this point, the patient and the parents have the

opportunity to evaluate the quality of life attained

with the treatment, understanding that this treat-

ment will most likely be for life. For many of these

patients, a sigmoid or rectosigmoid resection can

provide symptomatic improvement leading to signif-

icant reduction in or complete elimination of laxa-

tives.

Rectosigmoid Resection

For the last 14 years, we have been performing a sig-

moid resection to treat select patients with severe

constipation [15, 16]. The very dilated megarec-

tosigmoid is resected, and the descending colon is

anastomosed to the rectum. In a recent review of

patients with anorectal malformations, 315 suffered

from severe constipation, were fecally continent,

but required significant laxative doses to empty

their colon. Of these, 53 underwent a sigmoid resec-

tion. The degree of improvement varied. Following

sigmoid resection, 10% of patients no longer

required laxatives, had daily bowel movements, and

no longer soiled; 30% decreased their laxative

requirement by 80%; and the remaining 60%

decreased their laxative requirement by 40%. These

349

patients must be followed closely because the con-

dition is not cured by the operation. The remaining

rectum is most likely abnormal, and without careful

observation and treatment of constipation, the

colon can redilate.

A possible alternative could be to resect the rec-

tosigmoid, including the rectum, down to the pecti-

nate line in a similar manner used for patients with

Hirschsprung’s disease and anastomose the nondi-

lated colon (which is assumed to have normal motil-

ity) to the rectum above the pectinate line. This is

particularly applicable to the patient with idiopathic

constipation who has normal sphincters and a nor-

mal anal canal. It should not be performed in

patients with anorectal malformations, because this

treatment eliminates the rectal reservoir, which may

impact continence in some patients.

The most dilated part of the colon is resected

because it is the most seriously affected. The nondi-

lated part of the colon is assumed to have a more nor-

mal motility. Clearly, there must be a more scientific

way to assess the dysmotile anatomy. Perhaps with

the emergence of new colonic motility techniques,

these studies will help with surgical planning. It does

seem that patients who improve the most are those

who have a more localized form of megarectosig-

moid. Patients with more generalized dilation of the

colon do not respond as well and may require a more

extensive resection. Perhaps in the future, these

observations can be corroborated, and results of

resection can be better predicted by noninvasive

modalities.

References

1. Peña A, Levitt MA (2002) Colonic inertia disorders.

Curr Probl Surg 39:666–730

2. Peña A (1995) Anorectal malformations. Semin Pedi-

atr Surg 4(1):35–47

3. Peña A, Guardino K, Tovilla JM et al (1998) bowel

management for fecal incontinence in patients with

anorectal malformations. J Pediatr Surg 33(1):133–137

4. Levitt MA, Peña A (2006) Treatment of fecal inconti-

nence. In: Holschneider AM, Hutson JM (eds) Anorec-

tal malformations in children: embryology, diagnosis,

surgical treatment, follow-up. Springer, Berlin Heidel-

berg New York, p 379

5. Peña A, Hong AR, Midulla P, Levitt M (2003) Reoper-

ative surgery for anorectal anomalies. Sem Pediatr

Surg 12(2):118–123

6. Kiesewetter WB (1967) Imperforate anus II. The

rationale and technique of the sacroabdominoperineal

operation. J Pediatr Surg 2:106

7. Rehbein F (1967) Imperforate anus: experiences with

abdomino-perineal and abdomino-sacro-perineal pull

through procedures. J Pediatr Surg 2:99–105

8. Levitt MA, Peña A (2006) Treatment of chronic consti-

pation and resection of the inert rectosigmoid. In:

Holschneider AM, Hutson JM (eds) Anorectal malfor-

mations in children: embryology, diagnosis, surgical

treatment, follow-up. Springer, Berlin Heidelberg New

York, p 417

9. Levitt MA Soffer SZ, Peña A (1997) Continent appen-

dicostomy in the bowel management fecal incontinent

children. J Pediatr Surg 32:1630–1633

10. Peña A, Levitt MA (2005) Imperforate anus and cloa-

cal malformations. In: Pediatric surgery, 4th edn.

Ashcraft KW, Holder TM, Holcomb W (eds) WB Saun-

ders, Philadelphia, pp 496–517

11. Marshall J, Hutson JM, Anticich N, Stanton MP (2001)

Antegrade continence enemas in the treatment of

slow-transit constipation. J Pediatr Surg 36:1227–1230

12. DeLorenzo C, Flores AF, Reddy SN, Hyman PE (1992)

Use of colonic manometry to differentiate causes of

intractable constipation in children. J Pediatr

120:690–695

13. Sarna SK, Bardakjian BL, Waterfall WE, Lind JF (1980)

Human colonic electric control activity (ECA). Gas-

troenterology 78:1526–1536

14. Cook BJ, Lim E, Cook D et al (2005) Radionuclear

transit to assess sites of delay in large bowel transit in

children with chronic idiopathic constipation. J Pedi-

atr Surg 40(3):478–483

15. Peña A, El-Behery M (1993) Megasigmoid-A source of

pseudo-incontinence in children with repaired

anorectal malformations. J Pediatr Surg 28:1–5

16. Levitt MA, Carney DE, Powers CJ et al (2003) Laparo-

scopically assisted colon resection for severe idiopathic

constipation with megarectosigmoid. Journal of Pedi-

atric Endosurgery & Innovative Techniques 7:285–289

350

M.A. Levitt, R.A. Falcone Jr., A. Peña

SECTION V

Future Perspectives

Introduction

As a common denominator of all the clinical aspects

treated in this book, there is the awareness of poten-

tial benefits derived from rational management of

fecal incontinence (FI) and the need for further

efforts to improve the effectiveness of traditional and

new treatments. Indeed, although progress made in

this field during the last few decades has been signif-

icant, the lack of detailed knowledge in the physiolo-

gy of fecal continence far too frequently makes the

application of therapeutic procedures empiric and

pragmatic. Moreover, there are discrepancies

between countries and regions in referring patients

to centers dedicated to FI management. This causes

different attitudes in performing a homogeneous

diagnostic workup, in application of similar strict

selection criteria to the variety of available treat-

ments, and in reporting results of the applied thera-

pies. Worldwide, national institutes for health inade-

quately support medical research on FI treatment,

even though the social, economic, and clinical

importance of FI to society has been very well recog-

nized. On the other hand, research into FI is all too

frequently sponsored only by companies with a com-

mercial interest in the subject.

Nevertheless, a number of priorities have been

identified. In 2002, the Consensus Conference

“Advancing the Treatment of Fecal and Urinary

Incontinence Through Research: Trial Design, Out-

come Measures, and Research Priorities” [1], empha-

sized the fields of primary interest (Table 1) to im-

prove knowledge and treatment of FI by further plan-

ning research programs. Representatives of all spe-

cialties involved in FI management contributed to

this conference. Even if the goal of the conference to

produce significant results in 5–10 years is very

ambitious, the relevance of the priorities identified

remains actual. Following the same schema of this

book, the conference emphasized: (1) pathophysio-

logical and behavioral aspects, (2) diagnostic prob-

lems, (3) treatment-related issues, and (4) aspects

related to specific clinical conditions.

Pathophysiological and Behavioral Aspects

Further studies investigating pathophysiological

mechanisms of FI is of crucial importance because

progress will have an impact on both diagnostic and

therapeutic strategies. Due to the possible multifac-

torial origin of FI and the existence of different clini-

cal presentations, basic research into the influence

played by each of the numerous factors involved in

continence control can be of help [2]. Future studies

must consider that the traditional assumption that

women younger than 65 years of age are at maximum

risk of FI because of obstetric trauma to anal sphinc-

ters or pudendal neuropathy is not true [3]. Preva-

lence of FI in men has been certainly underestimated.

Also, other causative factors, different than those

secondary to childbirth, have to be of primary inter-

est, these being neuropathies (diabetes, multiple scle-

rosis, Parkinson’s disease, spinal cord injury, sys-

temic sclerosis, myotonic dystrophy, amyloidosis)

and conditions related to idiopathic FI. Moreover,

conditions affecting general health or ability to per-

form daily activities (stroke, immobility) are signifi-

cantly related to FI. These features could explain why

nursing home residence is the most prominent factor

associated with FI in patients affected by the above-

mentioned diseases.

The real role of sphincter tears, recent or previous,

in the development of FI is being rethought, not only

in relation to the pathophysiological aspect but also

to treatment strategy. Primary conditions and associ-

ated factors need to be elucidated in regard to

whether a limited or extended (how long? how large?)

lesion involving either or both internal and external

anal sphincters has caused FI [4–6]. Relationships

between sphincter integrity and anorectal sensorial

perception should be deeply studied, because they

probably are the interpretation key of positive effects

recently observed using sacral nerve stimulation

(SNS) in patients with iatrogenic FI. On the other

hand, nontraumatic FI is worthy of special attention

because of the complexity of patterns possibly

involved. Studies with electrophysiological tech-

Future Perspectives in Management and

Research of Fecal Incontinence

Carlo Ratto,Angelo Parello, Lorenza Donisi, Francesco Litta,

Giovanni B. Doglietto

niques, magnetic resonance imaging (MRI), and

positron emission tomography (PET) could explain

aspects of the correlation between the central nerv-

ous system (CNS) and targeted pelvic organs

involved in fecal and urinary continence. This will

contribute to a more rational application of SNS

using adequate criteria for patient selection [7].

Behavior in relation to FI is of unique impact on a

patient’s lifestyle and quality of life (QoL). Coping

mechanisms should be analyzed in different sub-

groups of patients according to their specific clinical

conditions [8–10]. For this purpose, adequate meth-

ods to measure coping mechanisms and behavior

related to FI severity should be found and used [11].

Unfortunately, each of the scales most often used to

measure QoL [12–18] has its strengths and weak-

nesses. Efforts should be directed to validate these

scales in translated versions in order to use compara-

ble forms in different countries [19].

Also, social stigma associated with FI must be

acknowledged and then addressed. Due to their reluc-

tance to confess to this disabling disorder, patients

often renounce or refuse any diagnosis and treatment.

Moreover, depression and anxiety affecting a very large

percentage of FI patients (larger than in urinary incon-

tinent patients) increase alienation from family and

354

C. Ratto, A. Parello, L. Donisi, F. Litta, G.B. Doglietto

Table 1. Priorities for treatment-related research on fecal incontinence (modified from [1])

Research priorities

Randomized controlled trials

Biofeedback vs. education and medical management

Biofeedback strength training vs. sensory training

Combined biofeedback plus surgery vs. each alone

Combined biofeedback plus drugs vs. each alone

Sacral nerve stimulation vs. biofeedback or surgery

Development of novel treatments

Develop and test new drugs

Identify the most effective surgery for obstetric tears

Optimize existing therapies

Improve adherence and maintenance

Evaluate long-term outcomes of surgery

Identify psychological symptoms that predict who consults

Geriatric population

Practical treatments for frail/demented elderly

Evaluate assisted toileting in nursing homes

Diagnostic tests

Develop normative values for diagnostic tests

Compare history and physical examination with diagnostic tests in predicting pathophysiology and response to

biofeedback

Evaluate electromyogram of external anal sphincter and puborectalis muscle for diagnosis of neurogenic fecal

incontinence

Evaluate relationship of quality of life to fecal incontinence severity

Standardize evaluation of severity and quality of life

Further studies of pathophysiological mechanisms

Prevention

Determine which diagnostic tests predict obstetric injury

Longitudinal studies of relationship of fecal incontinence to functional gastrointestinal disorders

Prevent anatomic defects leading to surgery by modifying behaviors (e.g., straining or hard stools)

Patient concerns

Counter social stigma associated with fecal incontinence

Provide better patient education regarding risk factors

Pediatric gastroenterology

Randomized controlled trial of laxative regimens in pediatric fecal incontinence

Compare enemas with oral laxatives in pediatric fecal incontinence

Compare enemas with toilet training in functional nonretentive fecal soiling

Randomized controlled trial comparing appendicostomy, colostomy, sphincter reconstruction, and artificial bowel

sphincter in spinal cord injury and anorectal malformations

Chapter 37 Future Perspectives in Management and Research of Fecal Incontinence

friends and create social isolation, with a significant

impact on the social costs attributable to the disease. All

these factors should be detailed and evaluated. There-

after, informative campaigns should be promoted and

psychological measures standardized to support these

patients. In particular, risk factors of FI must be illus-

trated to subjects who are potentially incontinent in

order to motivate them to investigate their condition.

Diagnostic Problems

Related to prevention of FI, of primary importance is

the identification of diagnostic tests predicting

sphincter lesions, not only obstetric [20] but second-

ary to other surgical procedures. Moreover, the rela-

tionship of FI to other functional gastrointestinal dis-

orders should be better investigated in order to

delimitate this subgroup of patients and address spe-

cific treatments [2].

The lack of homogeneity in the diagnostic workup

for FI should be solved. One measure could be the

identification of reference centers in which all the

basic diagnostic tools are available and procedures

performed according to largely shared standards

[21]. Efforts must be made to improve diagnostic

accuracy of anorectal tests, and normative values for

each diagnostic test should be provided according to

patients’ age and gender [22]. The actual difficulty of

finding measurable physiological parameters predict-

ing FI severity, as well as treatment outcome, should

be overcome by specifically designed trials using

standard procedures for anorectal manometry

(ARM) plus rectal sensory assessment, endoanal

ultrasound (EAUS), and anorectal electrophysiology

(AREP) in order to definitely establish the diagnostic

value of each diagnostic tool alone and together in a

multimodal diagnosis [23]. A specific set of parame-

ters should be identified for each condition as a min-

imum required standard [24–26]. Moreover, other

procedures (MRI, contrast defecography, and MRI

defecography) could be selectively used in specific

clinical conditions. Due to the large – and often con-

trasting – amount of data available in the literature

concerning the diagnostic and prognostic value of

physiological parameters [27–29], an accurate revi-

sion is desirable with the aim of achieving consensus.

It would be beneficial to relate diagnostic and prog-

nostic parameters to specific treatment options in

order to elucidate the therapeutic potentials of each.

Treatment-Related Issues

Randomized controlled trials (RCTs) demonstrating

not only effectiveness but also therapeutic validation

are needed concerning almost all of the available

treatments (biofeedback, sphincteroplasty, medica-

tions). The 2002 Consensus Conference [1] highlight-

ed the necessity to obtain evidence of potential bene-

fits using different treatment combinations utilizing

synergistic effects of combined therapies in compar-

ison with a single approach. This concept remains an

actuality: combination of biofeedback plus surgery

vs. each alone, or combination of biofeedback plus

medications vs. each alone could be useful compar-

isons. SNS frequently holds a central position in the

therapeutic algorithm for treating an increasing vari-

ety of FI conditions (following failed behavioral ther-

apies and preceding anal sphincter replacement

operations); however, its role needs to be confirmed

in RCTs designed in specific situations. From this

perspective, it will be interesting to confirm the effec-

tiveness of SNS both in FI patients with sphincter

lesions already treated with overlapping sphinctero-

plasty and in those with untreated sphincter tears.

This is according to the aim of future research to

optimize existing therapies, improving adherence

and maintenance, and evaluating long-term results

of a certain approach. This pertains, in particular, to

behavioral therapies [30] because they are often con-

sidered first-line therapy for FI, being safe, effective,

and inexpensive; it will be interesting to establish the

impact for patients of changing from behavioral ther-

apy to surgery.

The most intriguing aspect for future research is

the development of novel treatments. Of course,

efforts will be directed to noninvasive (new drugs) or

minimally invasive (bulking agents, miniaturized

devices) procedures [31–33]. On the other hand,

establishing correct indications for available treat-

ments could allow identification of the most effective

surgery for each FI condition [34, 35].

Aspects Related to Specific Clinical Conditions

A wide review of FI management in specific clinical

conditions is presented in the previous chapters of

this book. The 2002 Consensus Conference [1] high-

lighted the necessity to focus attention primarily on

geriatric and pediatric patients. Concerning older

subjects, it is very important to counterbalance

attempts to cure with patient frailty. Therefore,

physicians should identify an adequate treatment for

each type of disability, including minimally invasive

surgery (implant of new, effective bulking agents)

and supportive measures (anal plugs). Nurse educa-

tion should be directed to improving assistance to

patients, both home and nursing home residents.

As to FI in pediatrics, randomized controlled

studies will elucidate the value of enemas, laxatives,

355

and toilet training in FI and fecal soiling. Moreover,

indications and use of surgical approaches should be

redefined in FI patients with anorectal malforma-

tions and spinal cord injury, and SNS may have a role

in neurogenic FI.

Special consideration will be dedicated in the

future to FI secondary to multimodal treatment (sur-

gery and chemoradiotherapy) for rectal cancer in

order to define the pathophysiologic contribution of

the multiple factors involved and to establish correct

indications to treatment.

Problems related to iatrogenic anal sphincter

lesions have been widely discussed. This is a field

with large perspectives toward changing the actual

approach due on one hand to documentation of the

possibility of sphincteroplasty failure [36, 37] and on

the other hand, to success with emerging therapies,

i.e., SNS. Further RCTs should determine pathophys-

iological factors due to sphincter tears, surgery tim-

ing (immediate or delayed), reconstruction modality

(end to end or overlapping), and, importantly, indi-

cations and contraindications to surgery [38–41].

Central and peripheral neuropathies (including

those diseases determining nerve dysfunctions)

require concentrated investigation to establish spe-

cific patterns of pathophysiology useful to address

treatment. In this regard, a significant decrease in

aggressive treatments (sphincter replacement sur-

gery) is anticipated in these conditions in the future,

whereas the increasing use of therapies directly

impacting pathophysiology (i.e., SNS) will be justi-

fied by pathophysiological evidence.

Finally, increased integration of knowledge and

cooperation between coloproctologists, urologists, and

gynecologists will improve the effectiveness of treat-

ment of double fecal and urinary incontinence [42–43].

This condition requires an accurate multimodal diag-

nostic assessment. Treatment could provide rehabilita-

tive procedures, surgery, or both: precise indications

toward the behavioral approach, prosthetic/recon-

structive surgery, or SNS need to be defined.

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keeper: a new bulking agent for patients with fecal

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ment of a novel, remote-controlled artificial bowel

sphincter through microsystems technology. Artif

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34. Tillin T, Gannon K, Feldman RA et al (2006) Third-

party prospective evaluation of patient outcomes after

dynamic graciloplasty. Br J Surg 93:1402–1410

35. Ruthmann O, Fisher A, Hopt UT et al (2006) Dynamic

graciloplasty vs artificial bowel sphincter in the man-

agement of severe fecal incontinence. Chirurg

77:926–938

36. Maslekar S, Gardiner AB, Duthie GS (2007) Anterior

anal sphincter repair for fecal incontinence: good

long-term results are possible. J Am Coll Surg.

204:40–46

37. Barisic GI, Krivokapic ZV, Markovic VA et al (2006)

Outcome of overlapping anal sphincter repair after 3

months and after a mean of 80 months. Int J Colorec-

tal Dis 21:52–56

38. Oberwalder M, Dinnewitzer A, Baig MK et al (2006) Do

internal anal sphincter defects decrease the success rate

of anal sphincter repair? Tech Coloproctol 10:94–97

39. Hayes J, Shatari T, Toozs-Hobson P et al (2006) Early

results of immediate repair of obstetric third-degree

tears: 65% are completely asymptomatic despite per-

sistent sphincter defects in 61%. Colorectal Dis

9:332–336

40. Kairaluoma MV, Raivio P, Aarnio MT et al (2004)

Immediate repair of obstetric anal sphincter rupture:

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41. Steele SR, Lee P, Mullenix PS et al (2006) Is there a role

for concomitant pelvic floor repair in patients with

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nence? Int J Colorectal Dis 21: 508–514

42. Kapoor DS, Thakar R, Sultan AH (2005) Combined

urinary and faecal incontinence. Int Urogynecol J

16:321–328

43. Soligo M, Salvatore S, Milani R et al (2003) Double

incontinence in urogynecologic practice: a new

insight. Am J Obstet Gynecol 189:438–443

357

anal canal

3–7, 9, 11, 14, 16, 35, 37, 40, 44, 46, 55–58, 91, 95–97,

100, 101, 103, 107, 109–112, 120, 122–124, 127, 130, 131,

137–139, 141, 142, 155, 167, 168, 171, 173, 174, 179, 180, 182,

190, 191, 193–198, 211, 221–224, 229, 230, 233, 234, 242, 246,

247, 251, 252, 254, 255, 261, 262, 270, 273, 275, 288, 294, 297,

299–301, 309, 318–321, 328, 333, 341, 342, 350

anal canal anatomy 120, 127

Anatomy 3, 9, 13–15, 95, 107, 108, 110, 114, 120–122, 127–130,

148, 179, 180, 205, 207, 251, 253, 268, 273, 274, 280, 293, 312,

335, 350

anal canal length 55, 91, 155, 174, 233

anal dilatation 37, 55, 56, 111, 241, 251, 252, 253, 255

anal sphincter 3–10, 13, 14, 35–37, 40, 43, 44, 46, 48, 51–58,

95–102, 107–114, 119–123, 127–131, 135, 137, 138, 140, 143, 155,

157, 164, 167–169, 173, 176, 179–182, 185, 186, 190, 191,

205–207, 209, 211, 213, 214, 221, 223–285, 227, 229, 230,

233–236, 241–243, 245, 251–256, 261, 262, 267–270, 273–277,

279, 280, 285–291, 293, 294, 298–301, 308–313, 317–322, 325,

327, 332–335, 353–356

anal surgery 36, 45, 54, 89, 90, 131

anococcygeal ligament 108, 109, 130, 138

anorectal angle 8, 37, 44, 91, 96, 100, 110, 142, 155, 168, 179,

182, 206, 262, 278

anorectal electrophysiology 136, 139, 144, 149, 154, 355

anorectal function 35, 40, 41, 97, 101, 102, 107, 114, 168, 195,

242, 267, 301, 301, 307, 308, 309, 312

anorectal manometry 91, 99–102, 136, 137, 144, 149, 154, 164,

169, 195, 242, 243, 245, 255, 311, 312, 355

anxiety 68, 69, 74, 80, 143, 310, 317, 354

artificial bowel sphincter 40, 156, 157, 186, 190, 193–197, 199,

201, 211, 213, 264, 280

autonomic dysfunction 298, 299, 308, 309, 310

autonomic nervous system 48, 294

balloon expulsion test

101

behavioral therapy 120, 355

bimanual examination of the rectovaginal septum 91

biofeedback 70, 71, 74, 96, 101, 102, 104, 105, 118, 119, 120, 144,

147, 154, 155, 167, 168, 182, 196, 205, 207, 208, 209, 218, 233,

234, 243, 263, 277, 314, 322, 323, 335, 354, 355

bladder 3, 5, 8, 27, 49, 50, 67, 95, 145, 186, 195, 213, 218, 219,

221, 242, 294–301, 313, 321, 325, 327, 328, 331, 332, 343

brain 13, 40, 43, 44, 49, 97, 98, 164, 222, 293, 294, 313

bulking agents 143, 148, 155, 158, 163, 164, 173, 205, 221, 224,

227, 243, 264, 280, 335, 345, 355

central nervous system (CNS)

9, 43, 47, 97, 98, 144, 145, 158,

164, 215, 236, 294, 296, 297, 320, 354

cerebrovascular disease 294, 295

cesarean section 107, 276, 334

chemoradiation 215, 241, 242, 325, 328

childbirth 20, 36, 50, 51, 54, 74, 114, 119, 121, 127, 128, 155, 205,

267, 273, 274, 276, 279, 280, 289, 290, 291, 313, 332, 333, 353

clinical assessment 89, 91, 98, 135, 143, 153, 154, 300, 311

coccygeus 3, 95, 130–132, 181

Colonoscopy 82, 100, 243, 261, 312

coloproctologists 356

colostomy 171, 172, 174, 185, 187, 190, 193, 194, 198, 199, 202,

207, 209, 314, 342, 343, 346, 348

congenital 45, 46, 84, 144, 341

conservative treatments 201, 335

constipation 13, 14, 18, 36, 40, 46–48, 57, 64, 65, 96, 120, 157,

163, 164, 173, 186, 188, 199, 200, 206, 216, 219, 255, 261, 262,

267, 295–299, 307, 308, 312, 321, 329, 334, 341–350

continence 3, 8, 13–15, 35, 37, 43, 44, 46–48, 50, 51, 53, 55,

56–58, 67, 68, 89, 92, 93, 95–100, 102, 103, 114, 119, 120, 131,

135, 136, 142–144, 148, 149, 153, 154, 167, 169, 176, 179, 181,

182, 185, 186, 191, 195–198, 200–202, 205–208, 211, 212, 219,

233, 234, 241–243, 245, 251–256, 262–264, 267, 275–278,

286–290, 293, 294, 308, 310, 313, 314, 318, 320–323, 331–333,

341, 342, 350, 353, 354

coping behaviors 75

coping mechanisms 43, 69, 76, 354

Crohn’s disease 29, 49, 97, 98, 163, 199, 208, 253

Defecography

119, 123, 124, 129, 142,–145, 148, 149, 154, 164,

172, 186, 277, 312, 355

degeneration 36, 45, 98, 112, 121–124, 143, 157, 213, 236, 242,

245, 269, 299, 310

dementia 36, 46, 47, 57, 97, 98, 294, 295, 317, 318, 320, 321, 334

depression 3, 57, 68, 69, 74, 75, 83, 167, 197, 212, 214, 288, 310,

314, 317, 354

diabetes 29, 36, 43, 45, 47, 48, 97, 98, 100, 101, 119, 138, 144, 145,

163, 182, 199, 295, 298, 307–310, 312–314, 317, 353

diagnosis 17, 67, 80, 82, 83, 89, 95, 98, 99, 102, 103, 107, 117,

119, 120, 123, 124, 143, 153, 164, 201, 208, 251, 261, 299, 307,

318, 319, 343, 354, 355

diarrhea 9, 40, 89, 91, 97, 98, 100, 102, 107, 111, 114, 136, 154,

157, 158, 163, 164, 172, 185, 186, 229, 298, 299, 317–319, 321,

322, 334, 343, 344, 349

digital examination 89, 91, 107, 143, 158, 243, 312, 320

Subject Index

double incontinence 68, 219, 317, 331, 332, 338, 339

dynamic graciloplasty 143, 153, 155–157, 169, 176, 185–188,

190, 211, 213, 218, 235, 243, 264

dyssynergia 15, 57, 101, 142

economics

79, 81

elderly 17, 20, 36, 43, 48, 57, 67, 91, 101, 109, 144, 145, 218, 224,

255, 261, 263, 265, 267, 278, 307, 317–321, 339, 354

Electromyography 119, 140, 144, 149, 176, 180, 182, 273, 296,

311, 312

Electrophysiology 136, 139, 144, 145, 149, 154, 164, 243, 245,

355

Embryology 3, 350

encopresis 18, 21, 57, 67, 341

endoanal ultrasound 51, 54, 58, 97, 107, 109, 119, 120, 131,

136, 138–140, 144, 148, 149, 154, 158, 164, 172, 174, 179, 180,

182, 223–225, 227, 241–243, 245, 246, 251, 252, 254–257, 262,

267, 269, 273, 274, 280, 355

Endoscopy 91, 100, 103, 136

Endosonography 101, 107, 108, 109, 110, 113, 118, 120–124,

127, 128, 133, 258, 267, 311

enterocele 91, 123, 124, 142, 157, 186

Epidemiology 17, 74, 307, 339

Etiology 18, 36, 43, 49, 50, 67, 69, 89, 97, 98, 100, 119, 157, 167,

208, 233, 241, 242, 251, 253, 255, 286, 293, 300, 332

European Quality of Life (EuroQol) 73

experience with fecal incontinence 76

external sphincter 3, 5–7, 9, 10, 14, 37, 46–48, 96, 119–124, 131,

149, 168, 180–182, 186, 241, 246, 251–255, 262, 274–279, 289,

310, 322, 331, 332, 341

family members

fecal continence 3, 8, 89, 102, 161, 167, 185, 195, 196, 198, 208,

211, 245, 267, 293, 294, 318, 322, 341, 342, 353

fecal incontinence 9, 10, 73–76, 79, 81–84, 89, 90, 92, 95–102,

119–124, 127–129, 131–133, 135, 137, 138, 140, 144, 145, 148,

149, 153, 158, 163, 167, 168, 171, 176, 185, 186, 189, 191, 193,

195–199, 201, 205–209, 211, 213–216, 218–220, 227, 229, 230,

233–236, 241, 244–246, 267–269, 273–277, 285–288, 290, 291,

293–301, 317–322, 325–329, 331, 335, 341–349, 353–356

Fecal Incontinence Quality of Life (FIQL) 197, 212, 214, 229,

288

fistula surgery 29, 55, 56, 111, 131, 251, 253

fistulotomy 43, 56, 90, 97, 98, 107, 114, 121, 171, 251, 253

Gastrointestinal Quality of Life Index (GIQLI)

gynaecologists 274, 285, 289

Gluteoplasty 155–157, 205–209

Gluteus muscle 185, 205–208

Gracilis muscle 156, 185–188, 191, 205, 206, 235, 243

graciloplasty 143, 153, 155–157, 169, 176, 185–188, 190, 191,

195, 198, 201, 206, 209, 211, 213, 218, 235, 243, 264

group therapy 69, 71

Health-Related Quality of Life (HRQoL) 73, 75, 76, 327

Hemorrhoidectomy 97, 98, 107, 111, 128, 131, 171, 321

hyposensitivity 13, 36, 57, 58, 100, 215

iatrogenic

45, 50, 55, 56, 98, 111, 144, 145, 157, 176, 205, 234,

241, 245, 251, 252, 257, 353, 356

iliococcygeus 4, 130, 132

Imaging 8, 13, 40, 89, 91, 96–98, 107–110, 119–124, 127–132,

136, 138, 143–145, 148, 172, 179, 267, 268, 274, 298, 312, 318,

322, 354

implantable stimulator 186

incidence 9, 10, 17, 18, 21, 51–57, 112, 196, 209, 235, 242, 252,

261, 273–276, 285, 295, 296, 298, 312, 331–333, 335

inflammatory bowel disease 29, 49, 89, 91, 136, 158, 172, 207,

229, 312

injectable bulking agents 155, 158, 221, 225, 227, 264

inspection 89, 99, 123, 136, 148, 172, 277, 312

– perineum inspection 89

– Valsalva maneuver 8, 90, 91, 342

instruments 10, 28, 73–76, 80, 81, 140, 153, 214, 222

internal sphincter 5, 7, 14, 46, 48, 49, 96, 97, 111, 119–123,

156–158, 180, 227, 230, 241, 245, 251–255, 262, 275, 279, 288,

289, 310, 331

interpretation of studies 19, 36, 143, 274, 325, 328

intussusception 14, 57, 58, 91, 119, 123, 124, 136, 142, 157, 186,

255, 261, 312, 332

irritable bowel syndrome 29, 35, 45, 49, 61, 68, 74, 97, 138,

154, 208, 308, 313, 321, 334

lateral sphincterotomy

54, 107, 251, 252

leads 47, 58, 101, 111, 119, 120, 214, 215, 218, 222, 296, 297, 314,

333, 342, 348

leakage 14, 18, 20, 26, 27, 30, 31, 43, 56, 57, 68, 91, 92, 99, 102,

119, 120, 124, 128, 153, 221, 224, 225, 244, 256, 269, 310, 331,

345, 346

levator ani 3, 4, 6, 13, 14, 44, 95, 96, 107, 108, 119, 131, 168,

179–181, 211, 278, 297, 333

Magnetic resonance defecography

142

Magnetic resonance imaging (MRI) 13, 96, 97, 107, 127, 129,

136, 144, 172, 179, 267, 268, 298, 312, 322, 335, 354

Manchester Health Questionnaire 74, 75

manometry 8, 36, 82, 91, 96, 99, 100, 101, 113, 120, 122, 136,

137, 144, 149, 154, 164, 169, 172, 180, 186, 195, 197, 206, 215,

230, 233, 242, 243, 245, 255, 257, 262, 273, 275, 277, 311, 334,

348, 355

maximum tolerated volume 137, 242, 243

medical treatment 40, 79, 154, 163, 193, 347, 348

megarectum 13, 14, 45, 47, 57, 91, 317, 318, 320, 321, 342

multimodal rehabilitation 167, 169

multiple sclerosis 43, 45, 47, 68, 97, 98, 101, 218, 294, 296, 332,

353

myelopathies 296

myenteric plexus 5, 96, 97, 242, 294–297

Myopathy 45, 46, 98, 304

360

Subject Index

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