Anorectal Hystolgic Function

We next assess anorectal physiologic function using a series of objective tests. Anal manometry can help determine resting tone and voluntary contraction pressure, indicative of internal and external sphincter function, respectively. Rectal sensitivity is determined by use of an inflatable rectal balloon. The rectoanal inhibitory reflex (RAIR) causes the anal canal to relax when the rectum is distended. The RAIR is absent in patients with Hirschprung's disease and is often lost following low anterior resection of the rectum. Absence of a normal RAIR indicates loss of the normal sampling reflex, which is associated with diminished postoperative continence. Electromyography can help document pelvic floor reinnervation, a marker of a previous denervating injury. Denervation is due to traction injury of the pudendal nerve, most commonly caused by stretching of the nerve during vaginal delivery or chronic straining during defecation. Most laboratories now use pudendal nerve terminal motor latency testing as a measure of pudendal nerve function, but the sensitivity and predictive capabilities of this test are controversial.

Cinedefecography is a dynamic radiologic test that demonstrates the anatomic relationships of the pelvic floor organs during rectal evacuation. We use a barium oatmeal paste administered by rectal enema; in female patients, a radiopaque vaginal contrast should also be used to clarify anatomic relationships. Defecography is unnecessary if anorectal physiology tests and ultrasonography have delineated an unequivocal diagnosis and treatment plan. However, defecography can be an invaluable aid to planning when incontinence is associated with other hard-to-define disorders, such as internal prolapse.

Severity and Impact

The evaluation of fecal incontinence is incomplete without measuring its severity and subjective impact on the patient. Such clinical issues inform patients' motivation to seek treatment and clinicians' motivation to provide it. Experienced practitioners informally measure severity while obtaining every patient's history, in order to formulate the most appropriate treatment plan. Using a reliable, validated measurement tool confers the advantages of a formalized method, comparison with other patients, assessment of treatment effectiveness, ability to follow results over time, and individual provider feedback. Furthermore, evidence suggests that clinical assessment, in contrast to physiologic testing, is the only truly meaningful way to predict treatment success (Buie et al, 2001). Numerous measurement tools of varying simplicity, reliability, validity, and sensitivity have been devised; unfortunately, no consensus regarding a criterion standard has been reached. A more complete discussion of fecal incontinence measurement tools is in the excellent review by Baxter and colleagues (2003).

The clinical evaluation of fecal incontinence should include measures of both severity and impact on quality of life. Although these factors are closely intertwined, they may show surprising divergence in many cases. For example, one patient may refuse to leave her home due to fear of incontinence to flatus, whereas another may be little impacted by occasional episodes of complete incontinence. Accordingly, severity and quality of life should be measured separately (Shelton and Madoff, 1997) Even in the absence of a commonly accepted standard measure of incontinence severity, the key features (frequency and nature of incontinent episodes) are largely agreed upon. We measure the impact of incontinence on quality of life using the validated Fecal Incontinence Quality of Life Scale (FIQL) (Rockwood et al, 2000).

Taken together, anorectal physiology testing and incontinence measurement tools provide essential guidance for treatment planning and are the key to meaningful review and comparison of treatment effectiveness.

Constipation Prescription

Constipation Prescription

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