Faecal incontinence : Aspects of diagnosis and treatment

Abstract: Rectal reservoir function and anal pressures were investigated using anorectal manovolumetry in 48 patients with faecal incontinence and in 25 control subjects. Resting and squeeze pressures were lower in patients (p<0.001), but no significant difference was seen concerning rectal sensibility or compliance. The primary defect in incontinent patients seems to be a sphincter dysfunction. Any reduction in rectal compliance is likely to be a secondary phenomenon.The longitudinal high pressure zone profile was evaluated in 156 patients and 25 healthy controls using anorectal manometry with a station pull-through technique, 1 to 6 cm from the anal verge. Resting and squeeze pressures were lower in patients (P<0.01-0.001) apart from the proximal half of the measured length during rest. The high pressure zone was shorter in patients (P<0.05). There was a more proximal pressure accumulation in patients at rest (P<0.05). The main difference between incontinent patients and controls was a greater magnitude of the pressure profile in the latter group.Results of neurophysiological investigation (pudendal nerve terminal motor latency (PNTML) and fibre density (FD)) were studied prospectively in 72 patients with faecal incontinence. Prolonged PNTML was found in 46% and increased FD in 82% of the patients. FD but not PNTML was correlated to clinical and manometric variables.A questionnaire used in the assessment of patients with faecal incontinence and constipation was evaluated prospectively for 36 patients with incontinence and 38 with constipation. Reliability and validity were judged acceptable. Faecal incontinence per se was reproducible, as was the need to wear a pad. Several items distinguished both patient groups from healthy controls (P<0.05-0.001).Effects of electrostimulation of the pelvic floor were studied in 24 patients with idiopathic (neurogenic) incontinence. The results were evaluated at 3 and 12 months with a questionnaire and anorectal manometry. Eleven patients (46%) reported improvement after 3 months, and 9 (38%) after one year. Variables reflecting sphincter competence did not improve.Functional results of anterior levatorplasty (n=31) and sphincteroplasty (n=20) for idiopathic incontinence or sphincter injury were evaluated at 3 and 12 months. Eighteen patients (58%) in the levatorplasty group reported continence to solid and loose stools after one year, as compared with two patients (6%) before surgery (P<0.01). The corresponding figures in the sphincteroplasty group were 50% and 11% (P<0.05). Improvements were also observed concerning social and physical handicap in both groups.In a randomised trial, the results of levatorplasty (n=33) were compared with electrostimulation (n=29) for idiopathic (neurogenic) faecal incontinence. Improved incontinence scores after 3 months were seen in 29 patients (88%) after levatorplasty compared with 19 patients (66%) after electrostimulation (P<0.05). Improvements concerning deferring time for stool and social and physical handicap were more pronounced after levatorplasty.