Gastroenterology 2016;150:1430–1442 Anorectal Disorders Satish S. C. Rao,1 Adil E. Bharucha,2 Giuseppe Chiarioni,3,4 Richelle Felt-Bersma,5 Charles Knowles,6 Allison Malcolm,7 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 This report defines criteria and reviews the epidemiology, questionnaires and bowel diaries are correlated,5 some pathophysiology, and management of the following com- patients may not accurately recall bowel symptoms6; hence, mon anorectal disorders: fecal incontinence (FI), func- symptom diaries may be more reliable. tional anorectal pain, and functional defecation disorders. In this report, we examine the prevalence and patho- FI is defined as the recurrent uncontrolled passage of fecal physiology of anorectal disorders, listed in Table 1,and material for at least 3 months. The clinical features of FI provide recommendations for diagnostic evaluation and are useful for guiding diagnostic testing and therapy. management. These supplement practice guidelines rec- ANORECTAL Anorectal manometry and imaging are useful for evalu- ommended by the American Gastroenterological Associa- fl ating anal and pelvic oor structure and function. Educa- tion7 and American College of Gastroenterology.8 We will tion, antidiarrheals, and biofeedback therapy are the not address anorectal symptoms secondary to a neurologic mainstay of management; surgery may be useful in re- or systemic disorder. The revised diagnostic criteria fractory cases. Functional anorectal pain syndromes are include a minimum duration of symptoms that were defined by clinical features and categorized into 3 sub- selected arbitrarily to avoid the inclusion of self-limited types. In proctalgia fugax, the pain is typically fleeting and conditions. 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 F1. Fecal Incontinence fi tenderness. Functional defecation disorders are de ned by Definition ‡2 symptoms of chronic constipation or irritable bowel Fecal incontinence (FI) is defined as the recurrent un- syndrome with constipation, and with ‡2 features of controlled passage of fecal material for at least 3 months. impaired evacuation, that is, abnormal evacuation pattern fl on manometry, abnormal balloon expulsion test, or We recognize that fecal staining of underwear may re ect impaired rectal evacuation by imaging. It includes 2 sub- poor hygiene, prolapsing hemorrhoids, or rectal prolapse types: dyssynergic defecation and inadequate defecatory rather than true FI, but for practical purposes it is included fi propulsion. Pelvic floor biofeedback therapy is effective for in the de nition of FI. Clear mucus secretion must be treating levator ani syndrome and defecatory disorders. excluded by careful questioning. Flatus incontinence is oftenincludedinthedefinition of anal incontinence but not fi fi Keywords: Anorectal Disorders; Fecal Incontinence; Con- in the current diagnosis of FI because it is dif cult to de ne fl stipation; Dyssynergic Defecation; Levator Ani Syndrome; when isolated passage of atus is abnormal. FI is often Anorectal Pain; Biofeedback Therapy. 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 norectal disorders are defined by specific symptoms of age.9 A 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 1–3 function. Consequently, the distinction between “organic” Abbreviations used in this paper: ARM, anorectal manometry; CI, confi- and “functional” anorectal disorders may be difficult in dence interval; DRE, digital rectal examination; EMG, electromyography; 1–3 FDD, functional defecation disorder; FI, fecal incontinence; IBS, irritable individual patient. bowel syndrome; MRI, magnetic resonance imaging; OR, odds ratio. Anorectal disorders, such as fecal incontinence, are Most current article usually defined by specific symptoms, but functional disor- © 2016 by the AGA Institute ders of defecation require symptoms and anorectal physi- 0016-5085/$36.00 4 ological testing. While bowel symptoms recorded by http://dx.doi.org/10.1053/j.gastro.2016.02.009 May 2016 Functional Anorectal Disorders 1431 Table 1.Functional Anorectal Disorders Impact on quality of life and psychosocial factors. Persons with FI report that poor bowel control F. Functional anorectal disorders restricts their social life; other issues pertain to toilet F1. Fecal incontinence F2. Functional anorectal pain location, hygiene/odor issues, coping strategies, fear, F2a. Levator ani syndrome physical activities, embarrassment, and unpredictability of 27 F2b. Unspecifed functional anorectal pain bowel habits. Co-existent psychological problems may F2c. Proctalgia fugax include anxiety and depression,28,29 poor self-esteem, and F3. Functional defecation disorders problems with sexual relationships.30 Quality of life issues F3a. Dyssynergic defecation can be evaluated by generic or disease-specificin- F3b. Inadequate defecatory propulsion struments, such as the Rockwood Fecal Incontinence Quality of Life Scale, modified Manchester Health Ques- tionnaire, Fecal Incontinence and Constipation Assessment Quality of Life scale. FI symptoms can also be Epidemiology assessed by Pelvic Organ Prolapse/Incontinence Sexual Prevalence. Several large community-based stud- QuestionnaireÀIUGA (International Urogynecology – 31–34 ies10 17 have suggested that FI is common, with a preva- Association). There is a significant correlation be- 31,35 lence ranging from 7% to 15% in community-dwelling tween symptom severity and QOL in FI. FI was asso- women, 18% to 33% in hospitals, and 50% to 70% in ciated with increased mortality in some, but not all 36–38 nursing homes.18,19 The prevalence is either compara- studies. but whether it is due to FI per se or condi- ble16,20 or lower in men than women.21,22 Some11,13,17,23 but tions associated with FI (age and comorbidity) is 16 not all16,24 studies reported a lower prevalence in African- unknown. American than white women, but similar prevalence Etiology and risk factors for fecal incontinence. The across races in men.24 Interestingly, the majority of patients etiology of incontinence is often multifactorial. Therefore, it seen in clinical practice are women. is more appropriate to focus on associated conditions, Variations in the prevalence of FI among studies may especially when they precede the onset of FI, and on risk reflect differences in survey methods, screening questions, factors for FI. In community surveys, bowel disturbances, reference time frame10,16,25 (1 year or past month), and especially diarrhea and rectal urgency, and the burden of definition of incontinence. Two studies evaluated the chronic illness were more important and independent risk ANORECTAL incidence of FI.23,26 In a community study (65 years and factors for FI than obstetric-related pelvic floor injury (eg, 2,16,26,39–41 older), the incidence of FI at 4 years was 17%, with 6% forceps use, complicated episiotomy). In a having FI at least monthly.23 In a follow-up community community-based cohort of 176 randomly selected women study (50 years and older), the incidence of FI was with FI and 176 without FI, the independent risk factors for 7.0%.26 FI were diarrhea (odds ratio [OR] ¼ 53; 95% confidence interval [CI]: 6.1À471), cholecystectomy (OR ¼ 4.2l 95% CI: 1.2À15), current smokers (OR ¼ 4.7; 95% CI: 1.4À15), rectocele (OR ¼ 4.9; 95% CI: 1.3À19), stress urinary in- Table 2.Common Causes of Fecal Incontinence continence (OR ¼ 3.1; 95% CI: 1.4À6.5), and body mass 41 Anal sphincter weakness index (per unit, OR ¼ 1.1; 95% CI: 1.004À1.1). Smoking, Traumatic: obstetric, surgical (eg, hemorrhoidectomy, internal external sphincter atrophy, and obesity are also risk fac- sphincterotomy, fistulectomy) tors for FI.2,11,13,17,41 Other conditions associated with FI Nontraumatic: scleroderma, idiopathic internal sphincter include advanced age, disease burden (comorbidity count, degeneration diabetes), anal sphincter trauma (obstetrical injury, prior Neuropathy surgery), and decreased physical activity.11,16,17,42,43 Peripheral (eg, pudendal) or generalized (eg, diabetes mellitus) Pelvic floor disorders Several diseases that affect anorectal sensorimotor dys- Rectal prolapse, descending perineum syndrome functions and/or alter bowel habits are also associated