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Editor's Notes

• #3: The internal anal sphincter is the continuation of the distal portion of the circular smooth muscle of the rectum.Continence is maintained by the integrated action of the external and internal anal sphincters, the puborectalis, the levator plate, and by intact sensory pathways. Also normal resting anal tone and resistance to opening.
• #4: It depends on the consistency of the stool, the capacity of the rectum, the preservation of a normal sampling reflex, normal anorectal sensation, Impairment of one or more of the above mechanisms, may result in incontinence.
• #5: The internal anal sphincter is maintained at a state of continuous contraction, providing the most important component of resting anal pressure. With age, resting pressures progressively fall, due to the gradual degeneration of the internal sphincter.
• #6: The external anal sphincter is part of a composite muscle encircling the internal sphincter. It enables voluntary control of continence. The external sphincter's response to stimuli (voluntary effort, increased intra-abdominal pressure, rectal distension, anal dilatation) is contraction. Maximal voluntary contraction can be maintained only for approximately 50 seconds after which, fatigue occurs, hence, merely providing a final control mechanism if fecal material enters the upper anal canal.
• #7: The normal response to rectal distention consists of: 1.a brief contraction of the rectum, 2.a more prolonged relaxation of the internal sphincter in the upper anal canal, the rectoanal inhibitory reflex, 3.a rectoanal contractile reflex of the external anal sphincter and the puborectalis in the lower anal canal, in response to the rectal distension.
• #8: The anal canal is normally closed at rest and during sleep, due to the constant activity of the internal sphincter which is reinforced by the tonic activity of the external anal sphincter and the puborectalis. Moreover, anal closure is assisted by the properties of the vascular anal cushions. They expand, to keep the anal canal closed and prevent leakage, when anal pressures fall. The importance of the anal cushions is obvious in patients who present anal soiling after hemorrhoidectomy, even with normal sphincter pressures. In resting conditions the anal sphincters undergo periodic increased contractions at a rate of about 15 per minute , with some reversal of peristaltic action, presumably helping to prevent leakage and returning fecal debris to the rectum.
• #11: absent rectal reservoir = sphincter-saving operations a. low anterior resection b. coloanal anastomosis c. ileorectal anastomosis d. ileoanal reservoir collagen vascular disease= 1. scleroderma 2. dermatomyositis 3. amyloidosis
• #12: A. anatomic sphincter defect 1. Traumatic a. obstetric injury i. third degree or fourth degree lacerations ii. episiotomy wound complications iii. forceps injury b. anorectal surgery i. anal fistula surgery ii. hemorrhoidectomy iii. sphincterotomy iv. dilatation or stretching injury 2. neoplastic 3. inflammatory B. pelvic floor denervation 1. primary ("idiopathic" neurogenic incontinence) a. pudendal neuropathy b. chronic straining at stool c. descending perineal syndrome d. vaginal deliveries 2. secondary a. injuries to spinal cord, cauda equina, pelvic floor nerves b. diabetic neuropathy C. congenital abnormalities 1. spina bifida 2. myelomenigocele 3. imperforate anus D. Miscellaneous 1. aging 2. rectal prolapse 3. other
• #13: Fecal incontinence in post partum women is attributed to sphincter impairment and to pudendal nerve damage. There is often a history of difficult vaginal delivery, cephalopelvic disproportion, forceps delivery and third degree perineal tear. Injury of the anal sphincter occurs as a result of midline episiotomies in 12 percent of patients and of mediolateral episiotomies in 2 percent.
• #14: A sphincter repair often has a successful outcome in these cases. In most of the patients though, incontinence is a result of pudendal neuropathy and/or perineal descent, and in these cases successful outcome is less likely. There is evidence that postpartum pudendal neuropathy, persists and may worsen with time. The end-result of pudendal neuropathy is a short anal canal, low anal pressures, delayed conduction, increased sphincter fiber density and anal anesthesia.
• #15: Assessment of the patient with fecal incontinence must include a thorough history, as the etiology of the problem may be the single most important criterion of therapy. Of great importance is the frequency, duration, and severity of incontinence (whether for flatus, liquid stool, or formed stool). The history should include enquiry into the possibility of steatorrhoea, neurologic information (including sensory loss), carefull obstetric and gynaecological operations history in female patients, and the impact of incontinence on the quality of life. All previous operations on the anus and rectum should be recorded, particularly anal dilatation, sphincterotomy, and operations for fistulae or hemorrhoids. Resections of the small and large bowel must also be noted.
• #16: True incontinence should be distinguished from urgency. Impaired rectal compliance is frequently responsible for urgency. These patients are unable to withhold stool for more than a few minutes. This type of incontinence occurs in patients with inflammatory diseases in the rectum or radiation proctitis, or after a coloanal anastomosis.
• #17: Incontinence may be sensory, which is characterized by the passage of feces without the patient being aware of it. Alternatively, it may occur with the patient being aware of it, but being unable to prevent it. This type of incontinence is attributed to motor deficiency, which usually occurs in patients with pelvic floor or sphincter injury, but intact innervation.
• #19: The surgical procedures used to treat incontinence are ? direct repair of the external anal sphincter ? posterior plication of the levator ani muscle ? encirclement of the anal canal either with synthetic material or by non-sphincteric muscle interposition ? a combination of the above procedures (total pelvic floor repair) ? artificial sphincter implantation
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• #22: Sacral nerve stimulation is innovative and has had a medium-term success with improvement of quality of life in over 80% of patients treated for faecal incontinence. These results are superior to other techniques in treating patients with severe refractory faecal incontinence, where current maximal therapy has failed. The technique is unique because there is a screening phase, which has a high predictive value. It is also associated with minimal complications that are usually minor. However, most published reports of sacral nerve stimulation for treatment of faecal incontinence were case studies and methods of assessing outcome were variable. Criteria for patient selection are evolving and are yet to be defined. The present paper critically reviews the publications to date on sacral nerve stimulation for treatment of faecal incontinence. This will form the basis for future evaluation of this emerging treatment of severe, intractable faecal incontinence. Randomized clinical trials like that of the Melbourne trial will further clarify the role and indications of sacral nerve stimulation for faecal incontinence.
• #23: There were no septic complications. With sacral nerve stimulation, mean incontinent episodes per week decreased from 9.5 to 3.1 and mean incontinent days per week from 3.3 to 1. Perfect continence was accomplished in 47 percent. In the sacral nerve stimulation group, there was a significant (P < 0.0001) improvement in fecal incontinence quality of life index in all four domains. By contrast, there was no significant improvement in fecal continence and the fecal incontinence quality of life scores in the control group. CONCLUSIONS: Sacral neuromodulation significantly improved the outcome in patients with severe fecal incontinence compared with the control group undergoing optimal medical therapy.outcome is not associated with severity of sphincter disruption