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Anorectal Disorders View metadata, citation and similar papers at core.ac.uk brought to you by CORE HHS Public Access provided by Carolina Digital Repository Author manuscript Author ManuscriptAuthor Manuscript Author Gastroenterology Manuscript Author . Author Manuscript Author manuscript; available in PMC 2017 September 25. Anorectal Disorders Satish S. C. Rao1, Adil E. Bharucha2, Giuseppe Chiarioni3,4, Richelle Felt-Bersma5, Charles Knowles6, Allison Malcolm7, and Arnold Wald8 1Division of Gastroenterology and Hepatology, Augusta University, Augusta, Georgia 2Department of Gastroenterology and Hepatology, Mayo College of Medicine, Rochester, Minnesota 3Division of Gastroenterology of the University of Verona, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy 4Division of Gastroenterology and Hepatology and UNC Center for Functional GI and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 5Department of Gastroenterology/Hepatology, VU Medical Center, Amsterdam, The Netherlands 6National Centre for Bowel Research and Surgical Innovation, Blizard Institute, Queen Mary University of London, London, United Kingdom 7Division of Gastroenterology, Royal North Shore Hospital, and University of Sydney, Sydney, Australia 8Division of Gastroenterology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin Abstract This report defines criteria and reviews the epidemiology, pathophysiology, and management of the following common anorectal disorders: fecal incontinence (FI), functional anorectal pain, and functional defecation disorders. FI is defined as the recurrent uncontrolled passage of fecal material for at least 3 months. The clinical features of FI are useful for guiding diagnostic testing and therapy. Anorectal manometry and imaging are useful for evaluating anal and pelvic floor structure and function. Education, antidiarrheals, and biofeedback therapy are the mainstay of management; surgery may be useful in refractory cases. Functional anorectal pain syndromes are defined by clinical features and categorized into 3 subtypes. In proctalgia fugax, the pain is typically fleeting and lasts for seconds to minutes. In levator ani syndrome and unspecified anorectal pain, the pain lasts more than 30 minutes, but in levator ani syndrome there is puborectalis tenderness. Functional defecation disorders are defined by ≥2 symptoms of chronic constipation or irritable bowel syndrome with constipation, and with ≥2 features of impaired evacuation, that is, abnormal evacuation pattern on manometry, abnormal balloon expulsion test, or impaired rectal evacuation by imaging. It includes 2 subtypes: dyssynergic defecation and Address requests for reprints to: Satish SC Rao, MD, PhD, FRCP (LON), Augusta University, Division of Gastroenterology and Hepatology, AD 2238, Digestive Health Center 1481 Laney-Walker Blvd, Augusta, Georgia 30912. [email protected]; fax: (706) 721-0331; office: 706-721-2238. Supplementary Material Note: The first 50 references associated with this article are available below in print. The remaining references accompanying this article are available online only with the electronic version of the article. Visit the online version of Gastroenterology at www.gastrojournal.org, and at http://dx.doi.org/10.1053/j.gastro.2016.02.009. Conflicts of interest The authors disclose the following: AEB is an inventor of the portable anorectal manometry catheter that has been licensed to Medspira Inc; AEB and Mayo Clinic have contractual rights to receive royalties from the licensing of this technology. GC is an advisory board member and speaker for Shire Italia and Takeda Italia. The remaining authors disclose no conflicts. Rao et al. Page 2 inadequate defecatory propulsion. Pelvic floor biofeedback therapy is effective for treating levator Author ManuscriptAuthor Manuscript Author Manuscript Author Manuscript Author ani syndrome and defecatory disorders. Keywords Anorectal Disorders; Fecal Incontinence; Constipation; Dyssynergic Defecation; Levator Ani Syndrome; Anorectal Pain; Biofeedback Therapy Anorectal disorders are defined by specific symptoms and, in the case of functional disorders of defecation, also with abnormal diagnostic tests. Our understanding of these disorders continues to evolve with the availability of newer techniques to characterize anorectal structure and function.1–3 Consequently, the distinction between “organic” and “functional” anorectal disorders may be difficult in individual patient. 1–3 Anorectal disorders, such as fecal incontinence, are usually defined by specific symptoms, but functional disorders of defecation require symptoms and anorectal physiological testing.4 While bowel symptoms recorded by questionnaires and bowel diaries are correlated,5 some patients may not accurately recall bowel symptoms6; hence, symptom diaries may be more reliable. In this report, we examine the prevalence and pathophysiology of anorectal disorders, listed in Table 1, and provide recommendations for diagnostic evaluation and management. These supplement practice guidelines recommended by the American Gastroenterological Association7 and American College of Gastroenterology.8 We will not address anorectal symptoms secondary to a neurologic or systemic disorder. The revised diagnostic criteria include a minimum duration of symptoms that were selected arbitrarily to avoid the inclusion of self-limited conditions. F1. Fecal Incontinence Definition Fecal incontinence (FI) is defined as the recurrent uncontrolled passage of fecal material for at least 3 months. We recognize that fecal staining of underwear may reflect poor hygiene, prolapsing hemorrhoids, or rectal prolapse rather than true FI, but for practical purposes it is included in the definition of FI. Clear mucus secretion must be excluded by careful questioning. Flatus incontinence is often included in the definition of anal incontinence but not in the current diagnosis of FI because it is difficult to define when isolated passage of flatus is abnormal. FI is often multifactorial and occurs in conditions that cause diarrhea, impair colorectal storage capacity, and/or weaken the pelvic floor (Table 2). FI is considered abnormal after toilet training has been achieved, generally around 4 years of age.9 Epidemiology Prevalence—Several large community-based studies10–17 have suggested that FI is common, with a prevalence ranging from 7% to 15% in community-dwelling women, 18% to 33% in hospitals, and 50% to 70% in nursing homes.18,19 The prevalence is either comparable16,20 or lower in men than women.21,22 Some11,13,17,23 but not all16,24 studies Gastroenterology. Author manuscript; available in PMC 2017 September 25. Rao et al. Page 3 reported a lower prevalence in African-American than white women, but similar prevalence Author ManuscriptAuthor Manuscript Author Manuscript Author Manuscript Author across races in men.24 Interestingly, the majority of patients seen in clinical practice are women. Variations in the prevalence of FI among studies may reflect differences in survey methods, screening questions, reference time frame10,16,25 (1 year or past month), and definition of incontinence. Two studies evaluated the incidence of FI.23,26 In a community study (65 years and older), the incidence of FI at 4 years was 17%, with 6% having FI at least monthly.23 In a follow-up community study (50 years and older), the incidence of FI was 7.0%.26 Impact on quality of life and psychosocial factors—Persons with FI report that poor bowel control restricts their social life; other issues pertain to toilet location, hygiene/odor issues, coping strategies, fear, physical activities, embarrassment, and unpredictability of bowel habits.27 Co-existent psychological problems may include anxiety and depression, 28,29 poor self-esteem, and problems with sexual relationships.30 Quality of life issues can be evaluated by generic or disease-specific instruments, such as the Rockwood Fecal Incontinence Quality of Life Scale, modified Manchester Health Questionnaire, Fecal Incontinence and Constipation Assessment Quality of Life scale. FI symptoms can also be assessed by Pelvic Organ Prolapse/Incontinence Sexual Questionnaire–IUGA (International Urogynecology Association).31–34 There is a significant correlation between symptom severity and QOL in FI.31,35 FI was associated with increased mortality in some, but not all studies.36–38 but whether it is due to FI per se or conditions associated with FI (age and comorbidity) is unknown.16 Etiology and risk factors for fecal incontinence—The etiology of incontinence is often multifactorial. Therefore, it is more appropriate to focus on associated conditions, especially when they precede the onset of FI, and on risk factors for FI. In community surveys, bowel disturbances, especially diarrhea and rectal urgency, and the burden of chronic illness were more important and independent risk factors for FI than obstetric- related pelvic floor injury (eg, forceps use, complicated episiotomy). 2,16,26,39–41 In a community-based cohort of 176 randomly selected women with FI and 176 without FI, the independent risk factors for FI were diarrhea (odds ratio [OR] = 53; 95% confidence interval [CI]: 6.1–471), cholecystectomy (OR = 4.2l 95% CI: 1.2–15), current smokers (OR = 4.7; 95% CI: 1.4–15), rectocele (OR = 4.9; 95% CI: 1.3–19), stress urinary incontinence (OR = 3.1; 95% CI: 1.4–6.5), and body mass index (per unit, OR = 1.1; 95% CI: 1.004–1.1).41 Smoking, external sphincter atrophy, and obesity
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