Pathogenesis and management of fecal incontinence in the adult.
In the author's opinion, post-anal repair remains the procedure of choice for patients with levator neuropathy and loss of anorectal angle. The operation is minimally invasive and relatively free of major complications. A knowledge of the anatomy of the perineum and in particular of the intersphincteric space is mandatory before undertaking such surgery. Any surgeon who is accustomed to performing internal anal sphincterotomy will already be accustomed to identifying the plane and the internal sphincter. Progression to performing post-anal repair is only a small step. On the other hand, gracilis transposition seems to be a procedure of considerable technical complexity. Also it must be difficult to gauge the tension of the repair correctly. Presumably it can be all too easy to make the repair too tight and cause a stricture or create a lax repair by leaving too long a length of tendon. However, in patients whose pelvic floor has failed to develop (e.g., in patients with rectal atresia) it is hard to imagine any procedure other than gracilis transposition which can possibly be considered. Clearly, post-anal repair in this case would be contra-indicated. Finally, it is always relevant to remember that colostomy has a creative role to play in the management of anorectal incontinence. In the elderly patient who has a severe atrophy of the pelvic floor the incontinent abdominal wall stoma may be considerably easier to manage than a perineal "stoma." Patients with fecal incontinence are depressed and embarrassed. They have often been told by friends, relatives, and their family doctor that there is little that can be done and not to complain. It is essential in the initial consultation with the patient that this defeatist attitude be countered. Much can be done to restore full function by relatively simple measures which may include surgery. For the surgeon they represent a very gratifying group of patients to treat.
Henry
M M
MM
D000328:Adult; D000368:Aged; D001003:Anal Canal / Q000601:surgery; D005242:Fecal Incontinence / Q000175:diagnosis / Q000209:etiology* / Q000601:surgery; D006801:Humans; D008875:Middle Aged