The epidemiology of anal incontinence and symptom severity scoring

For many patients,anal incontinence(AI)is a devastating condition that can lead to social isolation and loss of independence,contributing to a substantial economic health burden,not only for the individual but also for the allocation of healthcare resources.Its prevalence is underestimated because of poor patient reporting,with many unrecorded but symptomatic cases residing in nursing homes.Endosonography has improved our understanding of the incidence of post-obstetric sphincter tears that are potentially suitable for repair and those cases resulting from anorectal surgery,most notably after fistula and hemorrhoid operations.The clinical scoring systems assessing the severity of AI are discussed in this review,along with their limitations.Improvements in the standardization of these scales will advance our understanding of treatment response in an era where the therapeutic options have multiplied and will permit a better comparison between specific therapies.

Sacral neuromodulation and peripheral nerve stimulation in patients with anal incontinence:an overview of techniques,complications and troubleshooting

Sacral neuromodulation(SNM)therapy has revolutionized the management of many forms of anal incontinence,with an expanded use and a medium-term efficacy of 75%overall.This review discusses the technique of SNM therapy,along with its complications and troubleshooting and a discussion of the early data pertaining to peripheral posterior tibial nerve stimulation in incontinent patients.Future work needs to define the predictive factors for neurostimulatory success,along with the likely mechanisms of action of their therapeutic action.

Adynamic and dynamic muscle transposition techniques for anal incontinence

Gracilis muscle transposition is well established in general surgery and has been the main muscle transposition technique for anal incontinence.Dynamization,through a schedule of continuous electrical stimulation,converts the fatigue-prone muscle fibres to a tonic fatigue-resistant morphology with acceptable results in those cases where there is limited sphincter muscle mass.The differences between gluteoplasty and graciloplasty,as well as the techniques and complications of both procedures,are outlined in this review.Overall,these techniques are rarely carried out in specialized units with experience,as there is a high revision and explantation rate.

Temperature-controlled radiofrequency energy in patients with anal incontinence:an interim analysis of worldwide data

Background:Controlled delivery of radiofrequency energy(SECCA procedure)as treatment for anal incontinence(AI)was introduced 15 years ago.Since then,several clinical studies have emerged.This article evaluates the clinical response and sustainability of SECCA for patients with AI.Methods:Only original clinical studies retrieved from PubMed and Medline were included.The outcome measures,faecal incontinence scores,definition of response,clinical results and anorectal evaluation were analysed.Results:Ten studies were included,which involved 150 original patients.Three studies reported a long-term follow-up.The one-year follow-up shows a moderate effect,which declines somewhat over time.Only minor temporary side-effects are reported and none of the patients declined treatment.Conclusion:SECCA is a safe and well-tolerated procedure that is easy to perform without any serious short-or long-term complications,but with only a moderate clinical effect that declines over time.Results of randomized,sham-controlled controlled trials are awaited.

Sphincteroplasty for anal incontinence

Sphincteroplasty(SP)is the operation most frequently performed in patients suffering from moderate-to-severe anal incontinence(AI)who do not respond to conservative treatment.Other costly surgeries,such as artificial bowel sphincter(ABS)and electro-stimulated graciloplasty,have been more or less abandoned due to their high morbidity rate.Minimally invasive procedures are widely used,such as sacral neuromodulation and injection of bulking agents,but both are costly and the latter may cure only mild incontinence.The early outcome of SP is usually good if the sphincters are not markedly denervated,but its effect diminishes over time.SP is more often performed for post-traumatic than for idiopathic AI.It may also be associated to the Altemeier procedure,aimed at reducing the recurrence rate of rectal prolapse,and may be useful when AI is due either to injury to the sphincter,or to a narrowed rectum following the procedure for prolapse and haemorrhoids(PPH)and stapled transanal rectal resection(STARR).The outcome of SP is likely to be improved with biological meshes and post-operative pelvic floor rehabilitation.SP is more effective in males than in multiparous women,whose sphincters are often denervated,and its post-operative morbidity is low.In conclusion,SP,being both low-cost and safe,remains a good option in the treatment of selected patients with AI.

Conservative treatment for anal incontinence

Anal incontinence(AI)in adults is a troublesome condition that negatively impacts upon quality of life and results in significant embarrassment and social isolation.The conservative management of AI is the first step and targets symptomatic relief.The reported significant improvement with conservative treatments for AI is close to 25%and involves prescribed changes in lifestyle habits,a reduced intake of foods that may cause or aggravate diarrhea or rectal urgency,and the use of specific anti-diarrheal agents.The use of a mechanical barrier in the form of an anal plug and the outcomes and principles of pelvic kinesitherapies and biofeedback options are outlined.This review discusses a gastroenterologist’s approach towards conservative therapy in patients referred with anal incontinence.

The use of a simple anal sling in the management of anal incontinence

Background.Many patients presenting with anal incontinence(AI)are frail,with attendant comorbidities precluding the use of complicated,expensive reconstructive techniques.In these cases,revisiting a simple approach—designed to provide some sort of effective barrier to stool—is worthwhile where the options include a customized peri-anal sling or the use of an anal plug.Methods.Analysis of an unselected cohort of 33 patients(mean age 54 years;range 27–86 years)with AI is presented,these patients having undergone insertion of an elastic band peri-anal sling between December 2004 and December 2009.Preand post-operative assessment included the Jorge-Wexner score of incontinence,anorectal manometry and the Rockwood Fecal Incontinence Quality of Life(FIQoL)score.Results.The follow-up period ranged from 50 to 108 months with a mean of 65 months.Early post-operative complications included spontaneous disruption of the sling at the fourth and seventh post-operative day in two patients and local infection in a further two cases.Late complications included skin erosion in two patients,(one occurring 3 years post-operatively)and breakage of the sling in a further seven patients.Explantation was performed in 13 cases,and re-implantation in 10 patients.No differences were noted in resting or squeeze manometry,with significant improvement in the Jorge-Wexner scores in 32 cases and in all of the four Rockwood quality of life scales.Conclusions.An anal sling is an effective and simple surgical option for the management of selected cases presenting with anal incontinence.Longer-term data are awaited comparing this technique with other standard surgical alternatives.

Excisional hemorrhoidal surgery and its effect on anal continence

AIM:To investigate the role of anal cushions in hemorrhoidectomy and its effect on anal continence of the patients.METHODS:Seventy-six consecutive patients(33 men and 43 women) with a mean age of 44 years were included.They underwent Milligan-Morgan hemorrhoidectomy because of symptomatic third-and fourth-degree hemorrhoids and failure in conservative treatment for years.Wexner score was recorded and liquid continence test was performed for each patient before and two months after operation using the techniques described in our previous work.The speed-constant rectal lavage apparatus was prepared in our laboratory.The device could output a pulsed and speed-constant saline stream with a high pressure,which is capable of overcoming any rectal resistance change.The patients were divided into three groups,group A(< 900 mL),group B(900-1200 mL) and group C(> 1200 mL) according to the results of the preoperative liquid continence test.RESULTS:All the patients completed the study.The average number of hemorrhoidal masses excised was 2.4.Most patients presented with hemorrhoidal symptoms for more than one year,including a mean duration of incontinence of 5.2 years.The most common symptoms before surgery were anal bleeding(n = 55),prolapsed lesion(n = 34),anal pain(n = 12) and constipation(n = 17).There were grade Ⅲ hemorrhoids in 39(51.3%) patients,and grade Ⅳ in 37(48.7%) patients according to Goligher classification.Five patients had experienced hemorrhoid surgery at least once.Compared with postoperative results,the retained volume in the preoperative liquid continence test was higher in 40 patients,lower in 27 patients,and similar in the other 9 patients.The overall preoperative retained volume in the liquid continence test was 1130.61 ± 78.35 mL,and postoperative volume was slightly decreased(991.27 ± 42.77 mL),but there was no significant difference(P = 0.057).Difference was significant in the test value before and after hemorrhoidectomy in group A(858.24 ± 32.01 mL vs 574.18 ± 60.28 mL,P = 0.011),but no obvious difference was noted in group B or group C.There was no significant difference in Wexner score before and after operation(1.68 ± 0.13 vs 2.10 ± 0.17,P = 0.064).By further stratified analysis,there was significant difference before and 2 months after operation in group A(2.71 ± 0.30 vs 3.58 ± 0.40,P = 0.003).In contrast,there were no significant differences in group B or group C(1.89 ± 0.15 vs 2.11 ± 0.19,P = 0.179;0.98 ± 0.11 vs 1.34 ± 0.19,P = 0.123).CONCLUSION:There is no difference in the continence status of patients before and after Milligan-Morgan hemorrhoidectomy.However,patients with preoperative compromised continence may have further deterioration of their continence,hence Milligan-Morgan hemorrhoidectomy should be avoided in such patients.

Incidence and Risk Factors of Obstetric Anal Sphincter Injuries after Various Modes of Vaginal Deliveries in Chinese Women

Background： Obstetric anal sphincter injuries （OASIS） can cause an adverse impact on women＇s physical and mental health. There was lack of published data in Chinese population particularly on studying the risk of OASIS for nonrotational outlet forceps. This study was to determine the incidence and risk factors of OASIS. Methods： This is a retrospective cohort study carried out in a tertiary referral hospital in Hong Kong. The control group was selected randomly. Univariate and multivariate logistic regression analysis was performed to evaluate the influence of potential risk factors on OASIS. This study reviewed the obstetric records of OASIS women and random control from January 2011 to June 2014. Univariate and multivariate logistic regression analysis was performed to evaluate the influence of potential risk factors on OASIS. Results： Of 15,446 women delivered, 49 had OASIS. The percentage of OASIS increased from 0.3% （2011） to 0.38% （2014）. There was an increasing trend of OASIS in attempted spontaneous vaginal delivery without episiotorny （P 〈 0.01）~ but it did not increase the OASIS risk （P = 0.46）. Univariate analysis of 49 cases and 438 control subjects showed that forceps delivery （odds ratio [OR] -8.73, P 〈 0.01 ）, prolong second stage of labor （OR = 1.43, P 〈 0.01） increased the risk lbr OASIS. In multivariate regression models, only lbrceps delivery （OR = 6.28, P 〈 0.01） proved to be independent risk factor. Conclusions： The incidence of OASIS in Chinese women was increased alter 2012, but still lower than the reported figures in the literature. Outlet forceps delivery could be a possible associated risk factor.

The antegrade continence enema procedure and total anorectal reconstruction

Patients may present with anal incontinence(AI)following repair of a congenital anorectal anomaly years previously,or require total anorectal reconstruction(TAR)following radical rectal extirpation,most commonly for rectal cancer.Others may require removal of their colostomy following sphincter excision for Fournier’s gangrene,or in cases of severe perineal trauma.Most of the data pertaining to antegrade continence enema(the ACE or Malone procedure)comes from the pediatric literature in the management of children with AI,but also with supervening chronic constipation,where the quality of life and compliance with this technique appears superior to retrograde colonic washouts.Total anorectal reconstruction requires an anatomical or physical supplement to the performance of a perineal colostomy,which may include an extrinsic muscle interposition(which may or may not be‘dynamized’),construction of a neorectal reservoir,implantation of an incremental artificial bowel sphincter or creation of a terminal,smooth-muscle neosphincter.The advantages and disadvantages of these techniques and their outcome are presented here.