IntUrogynecolJ DOI 10.1007/s00192-016-3140-3 SPECIAL CONTRIBUTION An International Urogynecological Association (IUGA)/ International Continence Society (ICS) joint report on the terminology for female anorectal dysfunction Abdul H. Sultan1 & Ash Monga2 & Joseph Lee3 & Anton Emmanuel4 & Christine Norton5 & Giulio Santoro 6 & Tracy Hull 7 & Bary Berghmans 8 & Stuart Brody9 & Bernard T. Haylen10 Received: 15 May 2016 /Accepted: 7 June 2016 # Wiley Periodicals Inc., and The International Urogynecological Association 2016 Abstract definition. An extensive process of twenty rounds of internal and Introduction and hypothesis The terminology for anorectal external review was developed to exhaustively examine each def- dysfunction in women has long been in need of a specific inition, with decision-making by collective opinion (consensus). clinically-based Consensus Report. Results A Terminology Report for anorectal dysfunction, Methods This Report combines the input of members of the encompassing over 130 separate definitions, has been developed. Standardization and Terminology Committees of two It is clinically based with the most common diagnoses defined. International Organizations, the International Urogynecological Clarity and user-friendliness have been key aims to make it inter- Association (IUGA) and the International Continence Society pretable by practitioners and trainees in all the different specialty (ICS), assisted on Committee by experts in their fields to form a groups involved in female pelvic floor dysfunction. Female- Joint IUGA/ICS Working Group on Female Anorectal specific anorectal investigations and imaging (ultrasound, radiol- Terminology. Appropriate core clinical categories and sub classi- ogy and MRI) has been included whilst appropriate figures have fications were developed to give an alphanumeric coding to each been included to supplement and help clarify the text. Interval This document is being published simultaneously in Neurourology and Urodynamics (NAU) and the International Urogynecology Journal (IUJ), the respective journals of the sponsoring organizations, the International Continence Society (ICS) and the International Urogynecological Association (IUGA). Standardization and Terminology Committees IUGA* &ICS# - Joseph Lee*,BernardT.Haylen*, Ash Monga#, Bary Berghmans# Joint IUGA/ICS Working Group on Female Anorectal Terminology - Abdul H. Sultan, Ash Monga, Joseph Lee, Anton Emmanuel, Christine Norton, Giulio Santoro, Tracy Hull, Bary Berghmans, Stuart Brody, Bernard T. Haylen Published online in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/nau.23055. * Abdul H. Sultan 5 Kings College London, London, UK [email protected] 6 Regional Hospital, Treviso, Italy 7 Cleveland Clinic Foundation, Cleveland, OH, USA 1 Urogynaecology and Pelvic Floor Reconstruction Unit, Croydon 8 Maastricht University Medical Center, Maastricht University, University Hospital, London Road, Croydon, Surrey CR7 7YE, UK Maastricht, The Netherlands 2 Princess Anne Hospital, Southampton, UK 9 Department of General Anthropology, Charles University, 3 University of Melbourne, Mercy Hospital for Women, Monash Prague, Czech Republic Health, Melbourne, Victoria, Australia 10 University of New South Wales, Sydney, New South Wales, 4 University College Hospital, London, UK Australia Int Urogynecol J review (5–10 years) is anticipated to keep the document updated forming a “backbone” or “core” terminology to which more and as widely acceptable as possible. specific terminologies can be attached [7]. Conclusions A consensus-based Terminology Report for fe- This Terminology Report is inherently and appropriate- male anorectal dysfunction terminology has been produced ly a definitional document, collating the definitions of aimed at being a significant aid to clinical practice and a stim- those terms, that is, words used to express a defined con- ulus for research. cept, in a particular branch of study. Emphasis has been on comprehensively including those terms in current use Keywords Anorectal . Fecal incontinence . Female sexual in the relevant peer-reviewed literature. The aim is to as- dysfunction . Female pelvic floor . Imaging . Terminology sist clinical practice and research. Some new and revised terms have been included. Explanatory notes on defini- tions have been referred, where possible, to the Introduction “Footnotes section.” Similar to a previous report [7] the female-specific termi- The anatomical configuration of the anorectum is complex. The nology report should be as follows: mechanisms that control continence and allow defecation are multifactorial and dependent on many factors such as the con- (1) User-friendly: It should be able to be understood by all sistency of stool, bowel transit, rectal compliance and sensitiv- clinical and research users. ity, intact neurological function and integrity of the pelvic floor, (2) Clinically-based: Symptoms, signs, and validated inves- and anal sphincters. tigations should be presented for use in forming work- Historically, anorectal physiological investigations have quite able diagnoses. The first three sections will address often produced inconsistent results. Until the advent of imaging symptoms, signs, and assessment tools. The next two techniques such as endoanal ultrasound, the etiology of fecal sections will describe anorectal physiological investiga- incontinence was largely attributed to pudendal neuropathy [1]. tions and currently used pelvic imaging modalities rou- We now better understand the contribution of vaginal delivery to tinely used in the office or anorectal laboratory to make anal sphincter trauma [2]. Imaging has taught us that training in those diagnoses. A number of related radiological inves- clinical digital assessment can improve detection and repair of tigations as well as magnetic resonance imaging (MRI) obstetric anal sphincter injuries and thereby minimize the risk of have also been included. The value of electromyography developing fecal incontinence [3]. Obstructive defecation is an- and related nerve conduction, reflex latency, and sensory other common embarrassing problem and imaging techniques investigations will be outlined. that attempt to capture the defecation process are often inconclu- (3) Origin: Where a term’ s existing definition (from one sive [4]. Artificial contrast material replicating normal fecal con- of multiple sources used) is deemed appropriate, sistency for defecating proctography is not available and mag- that definition will be included and duly referenced. netic resonance imaging requires an upright scanner. A number of terms in female anorectal function and When multiple conditions such as fecal incontinence, ob- dysfunction, because of their long-term use, have structive defecation, urinary incontinence, neurological dis- now become generic, as apparent by their listing in eases, medical conditions etc. co-exist, management becomes medical dictionaries. increasingly difficult and multidisciplinary assessment becomes (4) Able to provide explanations: Where a specific explana- important [5]. As the pelvic organs (bowel, bladder, and vagina) tion is deemed appropriate to explain a change from ear- are in close proximity to each other, clinicians need to be aware lier definitions or to qualify the current definition, this of the impact of dysfunction and surgery of one organ may have will be included as an addendum to this paper (Footnote on the neighboring structures. It is therefore important for cli- [FN] 1,2,3 .. .). Wherever possible, evidence-based nicians and pelvic surgeons to have more global knowledge and medical principles will be followed. adopt a holistic approach to pelvic floor dysfunction. It is suggested that acknowledgement of these stan- There is a need for standardized terminology in female dards in written publications related to female anorectal anorectal dysfunction to accumulate accurate prevalence data, dysfunction, be indicated by a footnote to the section perform the appropriate investigations, institute management, “Methods and Materials” or its equivalent, to read as and conduct audit and research. Lack of a unified definition of follows: “Methods, definitions and units conform to the anal incontinence has resulted in variations in prevalence data standards jointly recommended by the International from epidemiological data. “Pseudo incontinence” with mu- Urogynecological Association and the International coid leakage (usually caused by organic colonic disease, die- Continence Society, except where specifically noted.” It tary sensitivity or fecal impaction) is often mistaken as fecal should be noted that the Working Group for this docu- incontinence as questionnaires do not quite differentiate them ment was formed and started generation of this document [6]. There is indeed the need for a general terminology, prior to the Rosier statement [8]. IntUrogynecolJ Symptoms (a) Fecal urgency warning time: time from first sensation of urgency to voluntary defecation or fecal incontinence. Symptom: Any morbid phenomenon or departure from the nor- (iv) Fecal (flatal) urgency incontinence [7]: Complaint of mal in structure, function, or sensation, experienced by the wom- involuntary loss of feces (gas) associated with (fecal) an and indicative of disease [9] or a health problem. Symptoms urgency. are either volunteered by, or elicited from the individual, or may (v) Tenesmus (NEW): A desire to evacuate the bowel, often be described by the individual’s caregiver [7, 10, 11]. accompanied