Faecal incontinence 1994: which test and which treatment?

Faecal incontinence is a disabling condition caused by: (1) sphincter damage caused by childbirth, anorectal surgery, trauma, fistulae and abscesses; (2) pudendal neuropathy ("idiopathic faecal incontinence") caused by stretch injury by long-standing constipation or prolonged labor; (3) diminished rectal compliance in proctitis, low anterior resection or small pouches; (4) faecal impaction causing paradoxal diarrhoea; (5) neurological disease involving the pelvic floor and or the central nervous system; (6) diarrhoea. Often several factors play a role in a patient. A medical history and physical examination will generally provide a reasonable diagnosis. Anorectal function tests can show one or more abnormalities. Anal manometry can show low sphincter pressures; rectal compliance can show a small rectal volume; anal mucosal sensitivity measurement can show a high threshold and neurophysiological tests can demonstrate diminished muscle activity and a delayed pudendal nerve motor latency. Anal endosonography and defaecography have a direct clinical impact. Anal endosonography is a promising diagnostic tool demonstrating sphincter defects, even those not previously suspected. A sphincter defect demonstrated by anal endosonography provides a solid basis for a sphincter repair. Defaecography can reveal an intussusception, which is an indication for performing a rectopexy in the incontinent patient. A suggested work-up of the incontinent patient is given in a table. Besides the classic surgical treatments such as sphincter repair, rectopexy and post-anal repair new (surgical) options have been tried. The most promising new therapy seems the dynamic gracilis repair.