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Bordeianou LG, Thorsen AJ, Keller DS, Hawkins AT, Messick C, Oliveira L, Feingold DL, Lightner AL, Paquette IM. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Fecal Incontinence. Dis Colon Rectum 2023; 66:647-661. [PMID: 37574989 DOI: 10.1097/dcr.0000000000002776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Affiliation(s)
| | - Amy J Thorsen
- Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Deborah S Keller
- Colorectal Center, Lankenau Hospital, Philadelphia, Pennsylvania
| | - Alexander T Hawkins
- Section of Colon and Rectal Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Craig Messick
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lucia Oliveira
- Anorectal Physiology Department of Rio de Janeiro, CEPEMED, Rio de Janeiro, Brazil
| | - Daniel L Feingold
- Division of Colon and Rectal Surgery, Rutgers University, New Brunswick, New Jersey
| | - Amy L Lightner
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ian M Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Complications Following Posterior Colporrhaphy With and Without Anal Sphincteroplasty: An Analysis of Cases in the National Surgical Quality Improvement Program Database. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:1257-1261. [PMID: 36368595 DOI: 10.1016/j.jogc.2022.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 10/18/2022] [Accepted: 10/19/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE We aimed to compare postoperative complications for patients undergoing posterior colporrhaphy with or without sphincteroplasty. METHODS A retrospective cohort of women undergoing posterior colporrhaphy with or without anal sphincteroplasty was completed using the National Surgery Quality Improvement Program (NSQIP) database (2012-2019). The primary outcome was a composite of important surgical complications, including wound complications, blood transfusion, hospital stay >48 hours, reoperation, readmission, and urinary tract infection. Multivariable logistic regression was used to adjust for important potential confounders, including age, BMI, diabetes, and anterior prolapse surgery. RESULTS A total of 5079 patients were included. Of these, 82 patients underwent a concurrent sphincteroplasty. The primary composite outcome occurred in 10.4% of patients having posterior colporrhaphy versus 19.5% having posterior colporrhaphy with sphincteroplasty. On multivariable analysis there was no increased odds of complication associated with concomitant anal sphincteroplasty (1.58, 95% CI 0.89-2.90, P = 0.12). CONCLUSION Nearly one in five women who have posterior colporrhaphy with anal sphincteroplasty had an important surgical complication. Higher complication rates may be related to patient factors, as this was not observed after adjustment for patient factors and additional surgical procedures. Sphincteroplasty may be considered with posterior colporrhaphy in select women.
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Combined rectopexy and sacrocolpopexy is safe for correction of pelvic organ prolapse. Int J Colorectal Dis 2018; 33:1453-1459. [PMID: 30076441 DOI: 10.1007/s00384-018-3140-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/28/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE Pelvic floor abnormalities often affect multiple organs. The incidence of concomitant uterine/vaginal prolapse with rectal prolapse is at least 38%. For these patients, addition of sacrocolpopexy to rectopexy may be appropriate. Our aim was to determine if addition of sacrocolpopexy to rectopexy increases the procedural morbidity over rectopexy alone. METHODS We utilized the ACS-NSQIP database to examine female patients who underwent rectopexy from 2005 to 2014. We compared patients who had a combined procedure (sacrocolpopexy and rectopexy) to those who had rectopexy alone. Thirty-day morbidity was compared and a multivariable model constructed to determine predictors of complications. RESULTS Three thousand six hundred patients underwent rectopexy; 3394 had rectopexy alone while 206 underwent a combined procedure with the addition of sacrocolpopexy. Use of the combined procedure increased significantly from 2.6 to 7.7%. Overall morbidity did not differ between groups (14.8% rectopexy alone vs. 13.6% combined procedure, p = 0.65). Significant predictors of morbidity included addition of resection to a rectopexy procedure, elevated BMI, smoking, wound class, and ASA class. After controlling for these and other patient factors, the addition of sacrocolpopexy to rectopexy did not increase overall morbidity (OR 1.00, p = 0.98). CONCLUSIONS There is no difference in operative morbidity when adding sacrocolpopexy to a rectopexy procedure. Despite a modest increase in utilization of combined procedures over time, the overall rate remains low. These findings support the practice of multidisciplinary evaluation of patients presenting with rectal prolapse, with the goal of offering concurrent surgical correction for all compartments affected by pelvic organ prolapse disorders.
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Chang TC, Chang SR, Hsiao SM, Hsiao CF, Chen CH, Lin HH. Factors associated with fecal incontinence in women with lower urinary tract symptoms. J Obstet Gynaecol Res 2013; 39:250-5. [PMID: 23294291 DOI: 10.1111/j.1447-0756.2012.01902.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM The aim of this study was to identify the factors associated with fecal incontinence in female patients with lower urinary tract symptoms. MATERIAL AND METHODS Data regarding clinical and urodynamic parameters and history of fecal incontinence of 1334 women with lower urinary tract symptoms who had previously undergone urodynamic evaluation were collected and subjected to univariate, multivariate, and receiver-operator characteristic curve analysis to identify significant associations between these parameters and fecal incontinence. RESULTS Multivariate analysis identified age (odds ratio [OR]=1.03, 95% confidence interval [CI]=1.01-1.05, P=0.005), presence of diabetes (OR=2.10, 95%CI=1.22-3.61, P=0.007), presence of urodynamic stress incontinence (OR=1.90, 95%CI=1.24-2.91, P=0.003), pad weight (OR=1.01, 95%CI=1.00-1.01, P=0.04), and detrusor pressure at maximum flow (OR=1.02, 95%CI=1.01-1.03, P=0.003) as independent risk factors for fecal incontinence. Receiver-operator characteristic curve analysis identified age≥55years, detrusor pressure at maximum flow≥35 cmH(2) O, and pad weight≥15g as having positive predictive values of 11.4%, 11.5%, and 12.4%, respectively, thus indicating that they are the most predictive values in concomitant fecal incontinence. CONCLUSIONS Detrusor pressure at maximum flow and pad weight may be associated with fecal incontinence in female patients with lower urinary tract symptoms, but require confirmation as indicators by further study before their use as screening tools.
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Affiliation(s)
- Ting-Chen Chang
- Department of Obstetrics and Gynecology, National Taiwan University College of Medicine and National Taiwan University Hospital, Taipei, Taiwan
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Xu X, Ivy JS, Patel DA, Patel SN, Smith DG, Ransom SB, Fenner D, Delancey JOL. Pelvic floor consequences of cesarean delivery on maternal request in women with a single birth: a cost-effectiveness analysis. J Womens Health (Larchmt) 2010; 19:147-60. [PMID: 20088671 PMCID: PMC2828240 DOI: 10.1089/jwh.2009.1404] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The potential benefit in preventing pelvic floor disorders (PFDs) is a frequently cited reason for requesting or performing cesarean delivery on maternal request (CDMR). However, for primigravid women without medical/obstetric indications, the lifetime cost-effectiveness of CDMR remains unknown, particularly with regard to lifelong pelvic floor consequences. Our objective was to assess the cost-effectiveness of CDMR in comparison to trial of labor (TOL) for primigravid women without medical/obstetric indications with a single childbirth over their lifetime, while explicitly accounting for the management of PFD throughout the lifetime. METHODS We used Monte Carlo simulation of a decision model containing 249 chance events and 101 parameters depicting lifelong maternal and neonatal outcomes in the following domains: actual mode of delivery, emergency hysterectomy, transient maternal morbidity and mortality, perinatal morbidity and mortality, and the lifelong management of PFDs. Parameter estimates were obtained from published literature. The analysis was conducted from a societal perspective. All costs and quality-adjusted life-years (QALYs) were discounted to the present value at childbirth. RESULTS The estimated mean cost and QALYs were $14,259 (95% confidence interval [CI] $8,964-$24,002) and 58.21 (95% CI 57.43-58.67) for CDMR and $13,283 (95% CI $7,861-$23,829) and 57.87 (95% CI 56.97-58.46) for TOL over the combined lifetime of the mother and the child. Parameters related to PFDs play an important role in determining cost and quality of life. CONCLUSIONS When a woman without medical/obstetric indications has only one childbirth in her lifetime, cost-effectiveness analysis does not reveal a clearly preferable mode of delivery.
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Affiliation(s)
- Xiao Xu
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan 48109, USA.
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Chan MC, Schulz JA, Flood CG, Rosychuk RJ. A Retrospective Review of Patients Seen in a Multidisciplinary Pelvic Floor Clinic. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2010; 32:35-40. [DOI: 10.1016/s1701-2163(16)34401-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Lacima G, Espuña M. [Pelvic floor disorders]. GASTROENTEROLOGIA Y HEPATOLOGIA 2009; 31:587-95. [PMID: 19091248 DOI: 10.1157/13128299] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Fecal and urinary incontinence are frequently associated, together with pelvic organ prolapse. The most important risk factors for pelvic floor disorders are vaginal delivery and chronic constipation. Irrespective of the symptom prompting the patient to seek medical attention and the specialist consulted, symptoms in other compartments must be investigated because patients rarely report them spontaneously. Patients with pelvic floor disorders should be evaluated by a multidisciplinary group of specialists. Complete evaluation includes urodynamics, anal manometry, endoanal ultrasonography and neurophysiologic study of the pelvic floor and is recommended in most patients, given that pelvic floor disorders have a complex and multifactorial pathophysiology and that all anatomic and functional abnormalities must be detected to provide the most appropriate treatment. Conservative treatment resolves or improves the problem in a large proportion of patients with mild-to-moderate symptoms. Surgery should be indicated in selected patients with careful evaluation to identify preoperatively all anatomical and functional defects that can be surgically corrected. The identification of risk factors and better knowledge of the prevalence and pathophysiology of this health problem will allow preventive strategies to be established and improve therapeutic outcomes.
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Affiliation(s)
- Gloria Lacima
- Unidad Motilidad Digestiva, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, Barcelona, España.
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Kapoor DS, Sultan AH, Thakar R, Abulafi MA, Swift RI, Ness W. Management of complex pelvic floor disorders in a multidisciplinary pelvic floor clinic. Colorectal Dis 2008; 10:118-23. [PMID: 18199292 DOI: 10.1111/j.1463-1318.2007.01208.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To identify symptom clusters, management strategies and survey patient satisfaction in our combined multidisciplinary pelvic floor clinic (PFC). METHOD Retrospective cohort study, patient satisfaction questionnaire. SAMPLE Secondary and tertiary referrals with complex pelvic floor disorders. MAIN OUTCOME MEASURES symptom clusters and treatment received; patient satisfaction. RESULTS A total of 113 new cases over a 3-year period. There were two main symptom clusters: (i) obstructed defaecation with rectoceles (n = 55); of these, 23 had abdominal sacrocolpopexy with rectopexy, six had transvaginal rectocele repairs; and (ii) of the 33 with double incontinence, 10 had anal sphincter repairs, five had tension-free vaginal tapes and two had colposuspensions. Patient satisfaction audit: 73% found the care to be excellent/good, 12% satisfactory and 6% unsatisfactory. CONCLUSION Combined PFCs led to a more pragmatic approach in treating patients' symptoms. Combined surgery was undertaken in one-fourth of patients and is associated with cost savings and a single recuperation period. Overall, patients rated this service very highly.
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Affiliation(s)
- D S Kapoor
- Mayday University Hospital, Department of Urogynaecology and Colorectal Surgery, London Road, Croydon, Surrey, UK
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Sexual function following anal sphincteroplasty for fecal incontinence. Am J Obstet Gynecol 2007; 197:618.e1-6. [PMID: 18060952 DOI: 10.1016/j.ajog.2007.08.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2007] [Revised: 04/16/2007] [Accepted: 08/06/2007] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The objective of the study was to assess sexual function following anal sphincteroplasty and determine associations between sexual function and fecal incontinence. STUDY DESIGN Women 1 year or longer following anal sphincteroplasty with or without other reconstructive surgery were matched to controls. Subjects were mailed the Female Sexual Function Index (FSFI), Fecal Incontinence Quality of Life (FIQOL), Fecal Incontinence Severity Index (FISI), and a general questionnaire. RESULTS Twenty-six cases and 26 controls responded; 73% were sexually active. Sexual function scores were similar between the groups. Seventeen sphincteroplasty patients and 8 controls complained of fecal incontinence at follow up. Significant correlations were found between FSFI domains and the FIQOL depression/self-perception scale, FISI fecal incontinence of solid stool, and total FISI. CONCLUSION Sexual activity and function was similar following anal sphincteroplasty, compared with controls, despite worse symptoms of fecal incontinence. Fecal incontinence of solid stool and depression related to fecal incontinence were correlated with poorer sexual function.
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Steele SR, Lee P, Mullenix PS, Martin MJ, Sullivan ES. Is there a role for concomitant pelvic floor repair in patients with sphincter defects in the treatment of fecal incontinence? Int J Colorectal Dis 2006; 21:508-14. [PMID: 16075237 DOI: 10.1007/s00384-005-0014-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/25/2005] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS More than half of all patients who undergo overlapping anal sphincter repair for fecal incontinence develop recurrent symptoms. Many have associated pelvic floor disorders that are not surgically addressed during sphincter repair. We evaluate the outcomes of combined overlapping anal sphincteroplasty and pelvic floor repair (PFR) vs. anterior sphincteroplasty alone in patients with concomitant sphincter and pelvic floor defects. PATIENTS AND METHODS We reviewed all patients with concomitant defects who underwent surgery between February 1998 and August 2001. Patients were assessed preoperatively by anorectal manometry, pudendal nerve terminal motor latency, and endoanal ultrasound. The degree of continence was assessed both preoperatively and postoperatively using the Cleveland Clinic Florida fecal incontinence score. Postoperative success was defined as a score of <or=5, whereas postoperative quality of life was assessed by a standardized questionnaire. RESULTS Twenty-eight patients (mean age 52.3 years) underwent overlapping anal sphincteroplasty. The mean follow-up was 33.8 months. Cleveland Clinic Florida scores postoperatively showed a significant improvement from preoperative values (14.2 vs 5.1, p<0.001). Seventeen patients (61%) underwent concomitant PFR with sphincteroplasty. Three patients (27%) without PFR and one patient (6%) with PFR underwent repeat sphincter repair due to worsening symptoms (p=0.15). Two patients with PFR and one patient without PFR ultimately had an ostomy due to a failed repair (p=0.66). Comparing patients with and without PFR, there was a trend toward higher success rates (71 vs. 45%) when pelvic prolapse issues were addressed during sphincter repair. CONCLUSION Concomitant evaluation and repair of pelvic floor prolapse may be a clinically significant component of a successful anal sphincteroplasty for fecal incontinence but warrant further prospective evaluation.
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Affiliation(s)
- Scott R Steele
- General Surgery Service, Department of Surgery, Madigan Army Medical Center, Fort Lewis, WA 98431, USA
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Abstract
The operative technique of sphincteroplasty is only for isolated disruption of the sphincter muscle. Patients best suited for surgical corrections are those in whom incontinence is secondary to an anterior (obstetrical) sphincter defect. Due to the disappointing long-term results, the operation may be postponed if appropriate. At present, firstline treatment often is a biofeedback training program. It is well known that a persistent defect after repair is associated with an immediate poor outcome From 1995 - 2003 we have performed 40 sphincteroplasty on 38 patients with a mean age of 34 (range 19 - 71) years. The long-term results the of sphincteroplasty are not so promising. 3 techniques are available for measuring quality of life: Descriptive measures. Severity measures, Impact measures Sphincteroplasty, despite poor long-term results, is the best surgical treatment option for isolated, preferably anterior sphincter defects.
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Affiliation(s)
- J Pfeifer
- Physiology Laboratory, Medical University Graz, Austria
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Lee PYH, Steele SR. Complete pelvic floor repair in treating fecal incontinence. Clin Colon Rectal Surg 2005; 18:55-9. [PMID: 20011341 DOI: 10.1055/s-2005-864082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Fecal incontinence is associated with 20 to 40% of the patients with pelvic floor prolapse. Successful management of fecal incontinence requires not only an understanding of anorectal function but also a thorough understanding of pelvic floor anatomy and how pelvic floor prolapse affects fecal continence. Imaging techniques have been instrumental in visualizing pelvic floor prolapse and have helped correlate surgical findings. Stabilization of the perineal body appears to be a key component to the success of pelvic floor repair and fecal continence, but the optimal repair is far from being established.
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Affiliation(s)
- Patrick Y H Lee
- The Colon and Rectal Clinic, Oregon Health & Science University, Portland, OR 97205, USA.
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Gearhart S, Hull T, Floruta C, Schroeder T, Hammel J. Anal manometric parameters: predictors of outcome following anal sphincter repair? J Gastrointest Surg 2005; 9:115-20. [PMID: 15623452 DOI: 10.1016/j.gassur.2004.04.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Controversy exists over the utility of manometry in the management of fecal incontinence. In light of newer methods for the management of fecal incontinence demonstrating favorable results, this study was designed to evaluate manometric parameters relative to functional outcome following overlapping sphincteroplasty. Twenty women, 29 to 84 years of age (mean age 50 years), with severe fecal incontinence and large (>or=50%) sphincter defects on ultrasound were studied. All participants underwent anal manometry (mean resting pressure, mean squeeze pressure, anal canal length, compliance), pudendal nerve terminal motor latency (PNTML) testing, and completed the American Society of Colon and Rectal Surgeons fecal incontinence severity index (FISI) survey before and 6 weeks after sphincter repair. Statistical analysis for all data included the Wilcoxon rank-sum test, Mann-Whitney test, and Spearman's correlation. Significant perioperative improvement was seen in the absolute resting and squeeze pressures and anal canal length. Overlapping sphincteroplasty was also associated with significant improvement in fecal incontinence scores (FISI 36 vs. 16.4; P=0.0001). Although no single preoperative manometric parameter was able to predict outcome following sphincteroplasty, preoperative mean resting and squeeze pressures as well as anal canal length inversely correlated with the relative changes in these parameters achieved postoperatively. These findings suggest that either the physiologic parameters studied are not predictive of functional outcome or the scoring system used is ineffective in determining function. The perioperative paradoxical changes in resting pressure, squeeze pressure, and anal canal length would support the use of overlapping sphincteroplasty in patients with significant sphincter defects and poor anal tone.
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Affiliation(s)
- Susan Gearhart
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Abstract
PURPOSE OF REVIEW To review last year's literature on combined fecal and urinary incontinence, highlighting the most recent contributions on prevalence, physiopathology, evaluation, and treatment. RECENT FINDINGS Prevalence studies of double incontinence are rare but both conditions are frequently associated with pelvic organ prolapse. Vaginal delivery and chronic straining are risk factors for double incontinence, and pudendal neuropathy may be responsible for deterioration of continence. Electrophysiological studies in patients with combined fecal and urinary incontinence are necessary to confirm this hypothesis. Patients with double incontinence should be evaluated by a multidisciplinary group of specialists. A complete evaluation including urodynamics, anal manometry, anal ultrasound and electrophysiologic tests is recommended in most cases. Conservative therapy including pelvic floor exercises combined with bladder training and biofeedback has been demonstrated to be effective. Surgery is indicated in very few selected patients and may be performed simultaneously for both fecal and urinary incontinence. New studies are necessary that focus on identification of other risk factors and preventive strategies before deterioration of continence occurs. SUMMARY Combined fecal and urinary incontinence is not uncommon and its pathophysiology involves multiple factors. These patients should be evaluated by a multidisciplinary group of specialists and offered appropriate measures to improve their quality of life.
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Affiliation(s)
- Gloria Lacima
- Digestive Motility Unit, Institute of Digestive Diseases Biomedical Research Institute August Pi Sunyer (IDIBAPS), Hospital Clinic, University of Barcelona, Spain.
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Abstract
PURPOSE OF REVIEW In this review we intend to overview the operations available for faecal incontinence with particular reference to recently published articles. RECENT FINDINGS Operations benefiting faecal incontinence in women are direct sphincter repair, dynamic graciloplasty, artificial anal sphincter and sacral nerve stimulation. Considerable benefit was demonstrated with these operations but not without complications. Studies with longer follow-up are required for better assessment of these operations. SUMMARY Surgery for faecal incontinence is indicated after failure of non-operative measures. Good results may be achieved.
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Affiliation(s)
- Nicholas Rieger
- University Department of Surgery, The Queen Elizabeth Hospital, Woodville, South Australia, Australia.
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