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In August 2013, the National Institutes of Health sponsored a conference to address major gaps in our understanding of the epidemiology, pathophysiology, and management of fecal incontinence (FI) and to identify topics for future clinical research. This article is the first of a two-part summary of those proceedings. FI is a common symptom, with a prevalence that ranges from 7 to 15% in community-dwelling men and women, but it is often underreported, as providers seldom screen for FI and patients do not volunteer the symptom, even though the symptoms can have a devastating impact on the quality of life. Rough estimates suggest that FI is associated with a substantial economic burden, particularly in patients who require surgical therapy. Bowel disturbances, particularly diarrhea, the symptom of rectal urgency, and burden of chronic illness are the strongest independent risk factors for FI in the community. Smoking, obesity, and inappropriate cholecystectomy are emerging, potentially modifiable risk factors. Other risk factors for FI include advanced age, female gender, disease burden (comorbidity count, diabetes), anal sphincter trauma (obstetrical injury, prior surgery), and decreased physical activity. Neurological disorders, inflammatory bowel disease, and pelvic floor anatomical disturbances (rectal prolapse) are also associated with FI. The pathophysiological mechanisms responsible for FI include diarrhea, anal and pelvic floor weakness, reduced rectal compliance, and reduced or increased rectal sensation; many patients have multifaceted anorectal dysfunctions. The type (urge, passive or combined), etiology (anorectal disturbance, bowel symptoms, or both), and severity of FI provide the basis for classifying FI; these domains can be integrated to comprehensively characterize the symptom. Several validated scales for classifying symptom severity and its impact on the quality of life are available. Symptom severity scales should incorporate the frequency, volume, consistency, and nature (urge or passive) of stool leakage. Despite the basic understanding of FI, there are still major knowledge gaps in disease epidemiology and pathogenesis, necessitating future clinical research in FI.

Summarises the forms and causes of urinary and faecal incontinence. Highlights the psychological mechanisms and psychopathology associated with incontinence, and provides management recommendations. Source: National Library of New Zealand Te Puna Matauranga o Aotearoa, licensed by the Department of Internal Affairs for re-use under the Creative Commons Attribution 3.0 New Zealand Licence.

Introduction Objectively evaluating the lack of bowel control (fecal incontinence) continues to be a challenge. Many have attempted to measure the severity of fecal incontinence and to evaluate its impact on the quality of life by developing standardized scoring systems. Some of these systems have been validated but none have achieved widespread use and all have limitations in evaluating pediatric patients. Methods A review of the literature was performed looking for validated scoring systems of fecal incontinence that are currently used for either adult or pediatric patients. The identified scoring systems were then critically analyzed and their applicability for managing fecally incontinent children considered. Results Thirteen of the most frequently used fecal incontinence scoring systems were selected (6 for adults and 7 for children). Quality of life questionnaires were excluded not only because of their length and complexity, but mostly because they do not accurately reflect a measurement of bowel control. Our analysis revealed that all pediatric scoring systems require some degree of interpretation as they included at least one subjective parameter. These unverifiable subjective parameters were: “sensation of rectal fullness”, “sphincter squeeze”, and “anal shape”. Equally problematic, the pediatric systems frequently focused on factors unrelated to fecal continence such as “frequency of bowel movements”, “rectal prolapse”, “abdominal pain”, “blood in the stool”, “leakage of urine”, “diarrhea”, and “constipation”. The most objective system found from our review is the Krickenbeck system, which focuses upon two objective factors. Those two factors are the absence of voluntary bowel movements and the presence of soiling in the underwear. The major weakness of the Krickenbeck system is that it does not allow for reassessment after medical or surgical interventions. In this paper, we propose a modification of the Krickenbeck system that allows for such an assessment to be applied to those patients who are able to achieve voluntary bowel movements with the aid of laxatives or constipating agents. Conclusions Most scoring systems are flawed because they invite bias and interpretation due to their subjective nature, while systems focused on measuring quality of life do not address the fundamental issue of bowel control. The Krickenbeck score seems to be the most applicable and objective method of evaluating bowel control in pediatric patients that may be more useful when modified to assess patients after medical intervention.

Background. Patients' perceptions of treatment outcomes are important in the management of early prostate cancer, but few studies have offered reliable and responsive measures to assess the likely side effects of the most common treatments. Objective. To develop indexes of urinary, bowel, and sexual function, and related distress. Research Design. Prospective cohort study of the outcomes of treatment for early prostate cancer, with self-administered questionnaires completed before treatment, and 3 and 12 months afterward. Hypothesized indexes, based on a clinical model of pathophysiological side effects of treatment, were defined and evaluated with respect to reliability and validity. Subjects. Patients (n = 184) undergoing radical prostatectomy or external beam radiotherapy for early prostate cancer. Measures. Urinary and bowel items pertained to frequency or intensity of symptoms of dysfunction; parallel items assessed symptom-related distress. Sexual dysfunction items assessed the quality of erections, orgasm, and ejaculation; distress was assessed by 2 items adapted from the MOS Sexual Problems (MOS-SP) scale. HRQoL was assessed by the SF-36 and Profile of Mood States. Results. Symptom and symptom-related distress indexes for urinary incontinence, urinary obstruction/irritation, bowel dysfunction, and sexual dysfunction were defined. Symptom and distress indexes in each domain were highly correlated. Responsiveness was substantial and varied by treatment in ways consistent with clinical experience. The indexes accounted for significant proportions of the variance in HRQoL measures. Conclusions. These indexes may be used in monitoring outcomes of treatment for early prostate cancer.

Fecal incontinence is a common disorder in children. Many children with fecal incontinence have psychosocial co-morbidity. In this study, the effect of psychosocial co-morbidity on the treatment outcome of children with fecal incontinence was evaluated. One hundred and fifty children with fecal incontinence were treated in a multidisciplinary program. All children had been treated unsuccessfully for at least one year before entering the program. The treatment consisted of laxative treatment, psychosocial interventions, and biofeedback training. Psychosocial co-morbidity was classified according to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV). One hundred and forty-one children were completely analyzed (102 boys, mean age 9.6 (range 6.5–16.5) years). Of these, 31 (22%) children had fecal incontinence without constipation and 110 (78%) children had fecal incontinence associated with constipation. In 95% of children, at least one psychosocial co-morbidity was present. Treatment was successful at 12 months in 69% of patients. Treatment was less successful in children with attention deficit hyperactivity disorder (ADHD), in children with parent–child relational problems, and in mentally retarded children. The results indicate that the early assessment and treatment of psychosocial co-morbidity might improve treatment response in children with fecal incontinence. Children with fecal incontinence are treated less successfully in the first year if they have ADHD, parent–child relational problems, or mental retardation. Psychosocial evaluation and the early assessment and treatment of psychosocial co-morbidity is indicated in order to improve response rate. Family counseling—aimed at improving parent–child relations—should be an integral part of a multidisciplinary treatment program for fecal incontinence.

Purpose The introductions of total mesorectal excision and double-stapling technique into colorectal surgery have promoted the clinical application of sphincter preservation. However, for the tumors localized on the middle or lower level of rectum, sphincter-preservation approaches might be problematic in some patients. We introduce in this report a new sphincter-preserving technique for low rectal cancer. Methods Between August 1999 and May 2004, 310 patients underwent ultralow anterior resection and colorectal/coloanal anastomosis by supporting bundling-up method for low rectal cancer localized in the lower third of rectum. Postoperative evaluation included anal function, anastomotic leakage, anastomotic stenosis, cumulative survival rate, and local recurrence. Results Three hundred ten patients received the sphincter-preserving operation without severe intraoperative complications. One patient died of lung dysfunction (0.3%). All patients had satisfactory anal function without soiling. The median follow-up was 84 months (9-136 months) and overall survival rate was 97.0% at 1 year, 73.5% at 3 years, and 66% at 5 years. Thirty-six patients (11.6%) patients developed local recurrence. Postoperative complications included anastomotic leakage (1.6%), anastomotic stenosis (2.5%), and local and distant recurrence (11.6% and 18.4%, respectively). Conclusions Ultralow anterior resection and colorectal/coloanal anastomosis by supporting bundling-up method may be one of the best choices of sphincter-preserving operation for low rectal cancer.

Aim: The aim of this study was to increase knowledge and understanding of the nature and experiences of incontinence in men one or more years post prostate surgery. Methods: This descriptive study used a sample of convenience. Two hundred and twelve male participants who had undergone prostate surgery more than a year ago were asked about their experiences of incontinence. Participants were asked to fill in two questionnaires: The Expanded Prostate Cancer Index Composite and the Incontinence Impact Questionnaire. Participants were also asked about their prostate surgery, their health seeking behaviour in relation to incontinence, the type of discharge information they were given, and demographic information. Results: Sixty-six percent of participants indicated that, in the last four weeks, their overall urinary function had been a problem and 36.3% reported their bowel habits were problematic, which affected the quality of their lives. In addition, 41% of participants reported that they were not given discharge information regarding the possibility of developing urinary incontinence and sexual problems post prostate surgery. Conclusions: Health care professionals should pay more attention to routinely providing information to all men regarding the possibility of developing incontinence or sexual problems post prostate surgery. This may assist them to better manage these problems.

In a retrospective study, we examined whether multidisciplinary treatment based on a biopsychosocial approach and carried out by a pediatric surgeon, a child psychologist, and a pediatric physiotherapist is successful in reducing defecation problems (incontinence and/or constipation) in children with operated anal atresia (AA) (mean age 6.9 +/- 4.01 years). A second question was whether this treatment is successful in young children aged 2-5 years. The multidisciplinary approach consisted of standard medical treatment and a behavioral program to teach children and their parents adequate defecation behavior including an adequate straining technique. Forty-three children aged 2-16 years were included: 27 boys and 16 girls with AA, of whom 26 had high or intermediate and 17 low AA. Besides continence and constipation, defecation behavior and straining technique were evaluated. The children improved significantly during treatment in all aspects of defecation. No differences in effect of treatment were found between young children (2-5 years) and older ones, so this treatment seems to be equally effective in both age groups. This study demonstrates that both somatic and behavioral factors contribute to the persistence of chronic defecation problems. It is concluded that treatment of these problems in patients with operated AA should include behavioral modification techniques.

Little is known about the levels of continence in children with cerebral palsy and what factors affect this. This study was conducted to determine levels of urine and stool continence in children with cerebral palsy in relation to their learning disability (LD) and mobility. The aim was to enable us to predict level of continence that can be achieved for these children with a given level of learning disability and mobility. Data were obtained from medical notes and by telephone interview on mobility, degree of learning disability and urine and stool continence of 55 children in Southern Derbyshire. Most of the children who have nil to moderate disabilities in learning and mobility were able to achieve a decent level of continence around a median age of three years. Therefore, their toilet training should be started at the usual age with ongoing support from parents/carers. In children with severe learning disability and severe immobility, the probability of continence is very slim after the age of eight years. After this age it may be better to divert resources to other aspects of care, for example nutrition and physiotherapy, to improve their quality of life.