[Update on fecal incontinence]. / Stuhlinkontinenz - ein Update.

Fecal incontinence is defined as an accidental loss of stool or the inability to control defecation. There are three subtypes of fecal incontinence: passive incontinence, urge incontinence and soiling. About 8% of the adult population suffer from fecal incontinence, but only 1/3 consults a doctor. Beside the individual handicap, fecal incontinence has a huge socio-economic impact. Causes of fecal incontinence are changes in the quantity or quality of the stool and structural or functional disorders. Diagnostics encompass the medical history, clinical examination including the digital rectal examination, imaging (particularly endoanal ultrasound) as well as functional diagnostics (anal manometry and defecography). Nowadays, the most promising conservative treatment option consists of loperamide and biofeedback therapy. The most successful invasive method is the sacral neuromodulation.

L'incontinence fécale est définie comme une perte accidentelle de selles ou l'incapacité de contrôler la défécation. Il y a trois types d'incontinence fécale: l'incontinence passive, le besoin irrépressible et les salissures. Approximativement 8% de la population adulte souffre d'incontinence fécale, mais seulement 1/3 d'entre eux consultent un médecin. En plus de l'handicap individuel, l'incontinence fécale a un impact socio-économique considérable. Les causes de l'incontinence fécale comportent des modifications de la quantité ou de la qualité des selles et des anomalies structurelles ou fonctionnnelles. L'approche diagnostique comporte l'anamnèse médicale, l'examen clinique incluant un toucher rectal, le recours à l'imagerie (en particulier l'ultrasonographie endoanale) et des examens fonctionnels comme la manométrie anale et la défécographie. Aujourd'hui le traitement conservateur le plus prometteur se base sur le loperamide et la thérapie par biofeedback. La méthode invasive la plus efficace est la neuromodulation sacrée.

Fecal incontinence: help for patients who suffer silently.

Once you've identified patients with this embarrassing condition, achieving optimal outcomes hinges on your familiarity with advances like sacral nerve stimulation.

[Functional outcome after hand-sewn versus stapled colonic J pouch anastomosis for rectal carcinoma]. / Anastomoses colo-anale manuelles (ACA) et colo-sus-anale mécaniques (ACSA) avec réservoir en J, après proctectomie pour cancer: comparaison des résultats fonctionnels.

STUDY AIM: The aim of this study was to compare the surgical and functional results of hand-sewn and stapled colonic J-pouch anastomoses after proctectomies for cancer. PATIENTS AND METHODS: Over a 6-year period, 120 patients had a laparotomic conservative rectal excision with total mesorectal excision but without intersphincteric dissection, for cancer of the mid- and lower rectum: the colonic J-pouch anastomosis was hand-sewn for 49 and stapled for 71 patients. The functional results were assessed at 1 year, by a questionnaire completed by the patient. RESULTS: Morbidity was 37% in the hand-sewn group and 38% in the stapled group (ns). Mean duration of surgery in the hand-sewn group was 288 minutes and in the stapled group, 246 minutes (p<0.001). At 1 year, the rate of perfect continence was 71% for the hand-sewn group and 76% for the stapled group (ns). Significantly, more patient from the hand-sewn groups used enemas (16% versus 3%, p<0.005). On the other hand, there was no significant difference between the two groups for wearing protection, urgency, number of stools a day or gas/stool discrimination. CONCLUSIONS: There is no major difference in either the surgical or functional results between hand-sewn or stapled colonic J-pouch anastomosis by laparotomy for rectal cancer. Because it is simpler and faster to perform, a stapled pouch is preferable when the tumor site so permits.

[Anal incontinence]. / Incontinence anale.

Anal incontinence today is more frequent than current estimates indicate. When a patient seeks care for this condition, its cause and severity are assessed by a careful history and clinical examination. Two essential atraumatic examinations are decision-support tools: transrectal ultrasound and anal manometry. Treatment should always be proposed. Surgery is necessary in some cases: obvious rupture of the external sphincter, if possible confirmed by transrectal ultrasound, should be directly repaired. Should this treatment fail, a repeated repair or a sphincter replacement (graciloplasty or artificial sphincter) is called for. Neuromodulation therapy is often indicated in the absence of obvious rupture, especially in cases of pudendal neuropathy.

Psychosocial co-morbidity affects treatment outcome in children with fecal incontinence.

Fecal incontinence is a common disorder in children. Many children with fecal incontinence have psychosocial co-morbidity. In this study, the effect of psychosocial co-morbidity on the treatment outcome of children with fecal incontinence was evaluated. One hundred and fifty children with fecal incontinence were treated in a multidisciplinary program. All children had been treated unsuccessfully for at least one year before entering the program. The treatment consisted of laxative treatment, psychosocial interventions, and biofeedback training. Psychosocial co-morbidity was classified according to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV). One hundred and forty-one children were completely analyzed (102 boys, mean age 9.6 (range 6.5-16.5) years). Of these, 31 (22%) children had fecal incontinence without constipation and 110 (78%) children had fecal incontinence associated with constipation. In 95% of children, at least one psychosocial co-morbidity was present. Treatment was successful at 12 months in 69% of patients. Treatment was less successful in children with attention deficit hyperactivity disorder (ADHD), in children with parent-child relational problems, and in mentally retarded children. The results indicate that the early assessment and treatment of psychosocial co-morbidity might improve treatment response in children with fecal incontinence. Children with fecal incontinence are treated less successfully in the first year if they have ADHD, parent-child relational problems, or mental retardation. Psychosocial evaluation and the early assessment and treatment of psychosocial co-morbidity is indicated in order to improve response rate. Family counseling--aimed at improving parent-child relations--should be an integral part of a multidisciplinary treatment program for fecal incontinence.

Trastornos funcionales colorrectoanales: diagnóstico y tratamiento de la constipación e incontinencia anal / Functional colorectal disorders: diagnosis and treatment of constipation and anal incontinence

Los trastornos funcionales colorrectales tienen una alta incidencia en la población general, principalmente la constipación y la incontinencia, y aún hoy son un desafio diagnóstico y terapéutico. Se estima una incidencia del 2.2 al 15 por ciento para la incontinencia y del 20 al 80 por ciento para la constipación. Se los define generalmente por sus síntomas o por el hallazgo anormal de alguno de los estudios realizados (evaluación de la velocidad de tránsito, el test de expulsión del balón, la manometría anorrectal, la videodefecatografía, la ecografía anal 2D/3D, la resonancia dinámica magnética del piso pelviano y la evaluación neurofisiológica del piso pélvico). Los conceptos fisiopatológicos de los trastornos colorrectoanales continúan evolucionando con el mejor conocimiento brindado por nuevas tecnologías para el estudio de las estructuras anatómicas y su función. Estos han permitido reclasificar pacientes con trastornos idiopáticos o funcionales, como así también discernir si una alteración orgánica genera otra funcional o viceversa. En general los pacientes padecen varias alteraciones, estructurales y/o funcionales que pueden contribuir a la sintomatología, pero que individualmente pueden no ser suficientes para explicarla. La precisión diagnóstica permite implementar tratamientos adecuados, mejora la calidad de vida de los pacientes y disminuye los costos en salud. Este relato aborda a la constipación e incontinencia, describe sus incidencias, etiologías y las opciones terapéuticas para cada caso. Se incluyen capítulos sobre anatomía y fisiología colorrectoanal y métodos de evaluación, biofeedback, ecografía 3D y resonancia magnética dinámica del piso pelviano.

Trastornos funcionales colorrectoanales: diagnóstico y tratamiento de la constipación e incontinencia anal / Functional colorectal disorders: diagnosis and treatment of constipation and anal incontinence

Los trastornos funcionales colorrectales tienen una alta incidencia en la población general, principalmente la constipación y la incontinencia, y aún hoy son un desafio diagnóstico y terapéutico. Se estima una incidencia del 2.2 al 15 por ciento para la incontinencia y del 20 al 80 por ciento para la constipación. Se los define generalmente por sus síntomas o por el hallazgo anormal de alguno de los estudios realizados (evaluación de la velocidad de tránsito, el test de expulsión del balón, la manometría anorrectal, la videodefecatografía, la ecografía anal 2D/3D, la resonancia dinámica magnética del piso pelviano y la evaluación neurofisiológica del piso pélvico). Los conceptos fisiopatológicos de los trastornos colorrectoanales continúan evolucionando con el mejor conocimiento brindado por nuevas tecnologías para el estudio de las estructuras anatómicas y su función. Estos han permitido reclasificar pacientes con trastornos idiopáticos o funcionales, como así también discernir si una alteración orgánica genera otra funcional o viceversa. En general los pacientes padecen varias alteraciones, estructurales y/o funcionales que pueden contribuir a la sintomatología, pero que individualmente pueden no ser suficientes para explicarla. La precisión diagnóstica permite implementar tratamientos adecuados, mejora la calidad de vida de los pacientes y disminuye los costos en salud. Este relato aborda a la constipación e incontinencia, describe sus incidencias, etiologías y las opciones terapéuticas para cada caso. Se incluyen capítulos sobre anatomía y fisiología colorrectoanal y métodos de evaluación, biofeedback, ecografía 3D y resonancia magnética dinámica del piso pelviano. (AU)

Trastornos funcionales colorrectoanales: diagnóstico y tratamiento de la constipación e incontinencia anal / Functional colorectal disorders: diagnosis and treatment of constipation and anal incontinence

Los trastornos funcionales colorrectales tienen una alta incidencia en la población general, principalmente la constipación y la incontinencia, y aún hoy son un desafio diagnóstico y terapéutico. Se estima una incidencia del 2.2 al 15 por ciento para la incontinencia y del 20 al 80 por ciento para la constipación. Se los define generalmente por sus síntomas o por el hallazgo anormal de alguno de los estudios realizados (evaluación de la velocidad de tránsito, el test de expulsión del balón, la manometría anorrectal, la videodefecatografía, la ecografía anal 2D/3D, la resonancia dinámica magnética del piso pelviano y la evaluación neurofisiológica del piso pélvico). Los conceptos fisiopatológicos de los trastornos colorrectoanales continúan evolucionando con el mejor conocimiento brindado por nuevas tecnologías para el estudio de las estructuras anatómicas y su función. Estos han permitido reclasificar pacientes con trastornos idiopáticos o funcionales, como así también discernir si una alteración orgánica genera otra funcional o viceversa. En general los pacientes padecen varias alteraciones, estructurales y/o funcionales que pueden contribuir a la sintomatología, pero que individualmente pueden no ser suficientes para explicarla. La precisión diagnóstica permite implementar tratamientos adecuados, mejora la calidad de vida de los pacientes y disminuye los costos en salud. Este relato aborda a la constipación e incontinencia, describe sus incidencias, etiologías y las opciones terapéuticas para cada caso. Se incluyen capítulos sobre anatomía y fisiología colorrectoanal y métodos de evaluación, biofeedback, ecografía 3D y resonancia magnética dinámica del piso pelviano. (AU)

Incontinencia fecal en el anciano / Faecal incontinence in the elderly

Es importante que los médicos consideremos la incontinencia fecal como un serio problema y no como una parte normal del envejecimiento. Con frecuencia, el paciente anciano no refiere su existencia y se deberá preguntar específicamente por su presencia. Muchos médicos desconocen que pueden existir tratamientos para la incontinencia fecal. Hay numerosas causas de incontinencia fecal, y las secundarias a traumatismos obstétricos, junto a la impactación fecal, son las más frecuentes. Una correcta historia clínica y una minuciosa exploración física permitirán descubrir la causa. El tratamiento conservador consistirá en antidiarreicos, dieta rica en fibra, "bio-retroalimentación" o enemas. Si falla el tratamiento médico, el paciente deberá ser evaluado por un equipo multidisciplinario que incluya a un cirujano. La meta final es mejorar la calidad de vida del paciente (AU)

Current urologic management of cloacal exstrophy: experience with 11 patients.

PURPOSE: Since 1980 the authors have treated 12 infants with cloacal exstrophy (10 classical and 2 variants). Eleven patients had repair, and are all surviving. The initial phases of management that led to improved survival have previously been reported. Quality of life is now a major focus for the cloacal exstrophy patient. During the past 10 years, nine of the 11 patients had lower urinary tract reconstructive procedures. This review evaluates experience with reconstructive efforts to achieve bowel and bladder control and to improve the quality of life in this complex group of patients. METHODS: Through review of patient charts and by patient interviews, data were collected to evaluate the ability to provide urinary and bowel control. A continence score was applied to provide a measure of success: voluntary control, 3; control with an enema program or intermittent catheterization, 2; incontinence with a well-functioning stoma, 1; and incontinence without a stoma, 0. The best continence score is 6 (genitourinary and gastrointestinal). Surgical complications, urodynamic and metabolic sequelae of continent urinary diversion were reviewed. RESULTS: At the time of the authors' previous report, eight of 11 patients had a continence score of 2 or less. Currently, eight of 11 patients have a score of 3 or better (five with enteric stoma and continent urinary diversion, two with enema program and continent urinary diversion, and one with enema program and continent bladder). Urinary-diversion procedures have included two gastric augmentations and five gastric reservoirs, two of which have required subsequent bowel augmentation. Gastric augmentations carry a definite risk of metabolic problems with three of our patients demonstrating significant episodes of metabolic alkalosis. In addition, results of urodynamic monitoring suggests that gastric reservoirs may be less compliant than reservoirs formed using other bowel segments. CONCLUSIONS: Modern principles of continent urinary diversion have been successfully applied to the cloacal exstrophy patient further improving their quality of life. Use of gastric flaps with preservation of intestinal length has been central to urologic reconstructive efforts. Use of stomach alone for formation of urinary reservoirs may produce suboptimal compliance, and composite ileogastric construction should be considered if the gastric flap is of marginal size.

[The classification and choice of the method of treatment in fecal incontinence in children]. / K voprosu o klassifikatsii i vybore metoda lecheniia nederzhaniia kala u detei.

Complex examinations of 682 children with fecal incontinence including the colonodynamic investigation, computed tomography of the pelvis and endorectal sonography have shown that disturbance of the reservoir function and defecation urge mainly take place in cases of functional disorders. Anal incontinence of an organic type can also arise without an injury of the sphincter apparatus as a result of prolapse of the mucose membrane or stenosis of the distal portion of the rectum. In such cases the operative treatment is indicated. In patients with the incompetent internal and partially injured external sphincter treatment should be started by conservative measures. When the function of the pubo-rectal muscle or of all the elements of the closing apparatus is disturbed the operative treatment is indicated. The operative correction is possible for neurogenic incontinence in order to create the ano-rectal angle. A classification of anal incontinence in children is proposed which takes into account the etiology, pathogenesis and allows the optimum treatments to be chosen.

[Endoanal ultrasonography, defecography, and enema of the colon in the radiologic study of incontinence]. / Ecografia endoanale, defecografia e clisma del colon nello studio radiologico dell'incontinenza.

In the last 3 years, the authors examined 564 patients with disturbed anorectal function. Of 41 incontinent subject in this series, 30 were retrospectively analyzed to assess the diagnostic contribution of double contrast barium enema, defecography and endoanal sonography. The authors propose a classification of fecal incontinence based on imaging findings: indeed, rectal incontinence can be distinguished from pelvic and sphincteral incontinence. Large bowel enema and defecography are the examinations of choice if rectal incontinence is suspected on the basis of clinical history and possible endoscopic, manometric and electromyographic findings. Defecography is suggested if pelvic incontinence is suspected, while anal endosonography is the exam of choice in case of suspected sphincteral incontinence. Especially thanks to the recent availability of the latter technique, today radiologists can directly visualize the anal sphincteral apparatus and its lesions, yielding objective evidence of this type of incontinence too. The authors report on both limitations and indications of each diagnostic method and conclude by stressing the fundamental role diagnostic imaging plays today in the study of this disorder.

Study protocols and functional results in 86 electrostimulated graciloplasties.

PURPOSE: This study analyzes different protocols adopted in 86 electrostimulated graciloplasties performed during the last eight years, comparing functional and manometry results in 63 patients. METHODS: Electrostimulated graciloplasties were performed to construct a neosphincter after surgical removal of the anorectum for cancer in 75 patients and to substitute the anal sphincter in 11 fully incontinent patients. An intermittent stimulation protocol, using external devices, was applied in the first 68 patients, while long-term stimulation was carried out with implantable stimulators and intramuscular electrodes in the last 18 patients. Sixty-three patients remaining under study were evaluated by questionnaires, continence scores, and manometry. RESULTS: In patients submitted to intermittent stimulation, continence was achieved in 71 percent of 42 "neosphincters" after rectal resection and in 33 percent of 3 incontinent patients. Adopting chronic stimulation, implantable stimulators and intramuscular electrodes, continence reached 100 percent and 83 percent, respectively. Significant differences were also observed in resting and voluntary pressure values between the intermittently and chronically stimulated patients. Incontinent patients showed after chronic stimulation significant increases in mean resting and maximum voluntary pressures: from 13.3 to 60.5 mmHg and from 32 to 103 mmHg, respectively (P < 0.01). CONCLUSIONS: This study confirms the efficacy of chronic stimulation and the validity of a bilateral, "one-time" graciloplasty to reconstruct or substitute the anal sphincter.