The evolution of evaluation and management of urinary or fecal incontinence and pelvic organ prolapse

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Fecal incontinence: Epidemiology, etiology, and mechanisms

Fecal incontinence (FI) is defined by the unintentional loss of solid or liquid stool whereas anal incontinence (AI) includes leakage of gas, with or without FI. The failure of control over this bodily process can result in loss of confidence, modesty, composure, and self-respect.1 Consequently, many individuals withdraw from their social lives and hide the problem from their families, friends, and health care providers. For example, in 1 study, less than one-third of patients with FI had

Measuring end points and metrics in FI

Although FI is not a life-threatening condition, it is certainly life-altering.78 To help these patients, it is important to determine who will benefit from simple interventions and who will require more invasive treatments. As such, taking a careful patient history is crucial to both the initial clinical evaluation in patients suffering from incontinence in addition to using this information to assess response to therapy.79 This history should include symptom onset, frequency, stool

Medical and behavioral treatment of FI

FI is defined as the involuntary passage or inability to control passage of stool through the anus. Besides being a common health care problem, it has a high negative effect on quality of life. This embarrassing problem affects both the community-dwelling population as well as nursing home residents. The aim of treatment is to restore continence and improve the quality of life. The treatment strategies include conservative measures, medical (pharmacological) treatment, biofeedback, plug

Surgery for FI

FI is a common and frustrating condition, affecting up to 18% of the population and contributing significantly to decreased quality of life.134 Complex relationships between anatomical integrity, neurologic function, underlying diseases, and stool consistency contribute to continence, and thus our understanding of optimal interventions is imperfect. Treatment frequently requires a combination of interventions. When patients present for consideration of surgical intervention, often they have

Novel and evolving therapies for FI

There is no doubt that the past 5 years have seen a paradigm shift in the management of FI. As detailed in the previous section, the surgical management of FI has seen the decline of anatomical reconstruction and the advent of profoundly successful functional therapy in the form of SNS. Nevertheless, progress marches on despite, or perhaps because of, the recent successes in treatment, and there continue to be novel approaches to FI, as well as the evolution of current and classic approaches.

Cost implications in the management of FI

The purpose of this section of the monograph is to focus on the overall financial effect of treatment of FI. Clinically there are 3 subtypes: (1) passive incontinence, the involuntary discharge of stool or gas without awareness; (2) urge incontinence, the discharge of fecal matter in spite of attempts to retain bowel contents; and (3) fecal seepage, the leakage of stool following otherwise normal evacuation.227 Equally important is the fact that the severity of symptoms can vary widely, and

Rectal prolapse: Epidemiology, etiology, and evaluation

Rectal prolapse is defined as the full-thickness, circumferential protrusion of the rectum through the anal orifice. In contrast, internal intussusception (also known as internal prolapse) is the intussusception of the middle or upper part of the rectum that does not reach the anal orifice. Some authors suggest that internal intussusception is the first phase in the development of complete external rectal prolapse. Rectal prolapse is further differentiated from mucosal prolapse, whereby there

Perineal surgical approaches to rectal prolapse

Full-thickness rectal prolapse is a relatively uncommon pelvic floor disorder, which mostly affects women and the elderly. The hallmark feature differentiating full-thickness prolapse from mucosal prolapse is the presence of concentric mucosal rings with full-thickness prolapse (Fig 15). Several risk factors have been described including multiparity, chronic constipation, and straining with defecation.291 Rectal prolapse can have an enormous effect on quality of life,292 and as such, many

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