Conservative (non-operative) and operative m easures are currently available for the m anagem ent of those w ith anorectal incontinence.
Conservative m easures
Conservative m easures should be tried in all patients except w hen the clinical features and results of investigations suggest an underlying pathology such as inflam m atory bow el disease, carcinom a or rectal p ro lap se w hich req u ire alternative, appropriate treatm ent. Patients should be counselled and given advice w ith the aim of producing a solid stool once each day. Opiates, such as loperam ide can be helpful. They have been dem onstrated to increase internal anal sphincter p ressu re and to inhibit the recto-anal inhibitory reflex via activation of opiate receptors (Read et aL, 1982; Rattan and Culver, 1987). A low fibre diet is recom m ended. Such m easures will be m ost beneficial in patients w ith m ild sym ptom s, especially if th eir p roblem is eith er tra n sie n t or interm ittent. A successful outcome has been reported in 40% of patients treated by diet and d rugs alone (Miller et a l, 1988). O thers how ever, have reported acceptable continence in only 16% of those treated sim ilarly (Keighley and Fielding, 1983).
O ther non-operative therapies include pelvic floor physiotherapy, biofeedback conditioning and electrical stim ulation. Prom ising early results have been reported for the latter w ith repeated stim ulation of the pudendo-anal reflex arc (Binnie et al., 1990). Biofeedback conditioning has been used successfully in som e centres, particularly in N orth Am erica (Macleod, 1987) and im proved rectal sensation is an im portant determ inant of outcome (Wald, 1983; M iner et aL,
1990). How ever, these techniques have not yet been show n to be of long term benefit and studies claim ing their success are flawed by lack of controls and im precise definitions of how continence w as assessed and graded. The only controlled study that has been perform ed did not show any difference betw een patients having biofeedback and controls (McHugh et al., 1986). This finding w as s u p p o rte d by Loening-Baucke (1990), w ho found th at biofeedback w as
ineffective and suggested that improvements noted in anorectal function m ay in fact be due to m edication or to regression of sym ptom s w ith time.
O perative measures
Principles of surgery in anorectal incontinence
Surgical intervention in anorectal incontinence is considered if conservative m easures fail to ameliorate the problem. Several techniques are available and their selection is determ ined by the aetiology of incontinence and the outcom e of previous treatments.
Direct sphincter injuries: These are explored through a peri-anal incision in
the area of the previously defined defect. The abrupted ends of the external sphincter are isolated by dissection and w ith the aid of per-operative nerve stim ulation. Enough muscle is mobilised to allow an overlapping repair over a reasonable distance cranially (3-4cm) so that an anal canal of adequate length can be reconstructed. The fibrous scar at the abrupted ends of the injured m uscle can be used to secure the overlap. The repair is perform ed using non-absorbable su tu res and, w here possible, the internal anal sphincter is also tightened by imbrication.
Post anal repair: This is the most commonly perform ed operation in cases
w here there is pelvic floor and external sphincter w eakness due to neuropathy. It w as conceived by Parks (1975) on the prem ise th at a 'flap valve' (above) is essential for norm al continence and that this is m issing in neurogenic faecal incontinence. Post anal repair attem pts to recreate acute anorectal angulation by m oving the anorectal junction upw ards and forwards.
The sphincters are first exposed through a curvi-linear or 'V shaped post anal incision and the intersphincteric plane is sought. This is the bloodless anatom ical key to the operation which, w hen entered and follow ed superiorly, leads u p to pelvic floor w here W aldeyer's fascia is incised to gain access to the p re-sacral space above. The levators (ileococcygeus, pubococcygeus and puborectalis) are approxim ated in tu rn u sing in te rru p te d non-absorbable sutures. The external sphincter is then imbricated w ith a similar suture.
Results of surgery
Following the repair of a direct sphincter injury, 70-90% of patients can expect to have full continence restored w ith less than 10% achieving no benefit at all (Browning and Motson, 1983. Fang et al, 1984).
The results of postanal repair are outlined in Table 2.
Table 2.
The outcom e of postanal repair for anorectal incontinence.
Fully continent Improved but not fu lly continent Not improved Keighley and Fielding 1983. n=39 27 (69%) 6 (15%) 6(15%) Browning and Parks 1983. n=42 8 (19%) 26 (62%) 8 (19%) W omack et al, 1988. n=16 6 (37%) 8 (50%) 2(12.5) Miller et a l, 1988. n=17 10 (59%) 4 (23%) 3 (18%) Scott et al, 1990. n=62 28 (45%) 23 (37%) 11(18%)
It is clear that although m ost patients gain some benefit from postanal repair, the quality of continence achieved is often imperfect. In addition, long term follow- u p indicates th at the functional outcom e deteriorates w ith tim e such th at by three years after surgery, 76% have soiling and 52% require the protection of p ad s (Yoshioka and Keighley, 1989). Failures occur due to technical problem s, the presence of concom itant proxim al disease such as the irritable bow el syndrom e, or because of continuing neuropathy w hich m ight result from the operation itself (Laurberg et aL, 1990).
The factors associated w ith a successful outcome after post anal repair rem ain uncertain. R estoration of acute anorectal angulation is n o t correlated w ith restitution of continence (Miller et aL, 1988; Womack et aL, 1988; Yoshioka et aL,
1988). Instead, operative success has been linked w ith other param eters, b u t w ith none unequivocally; increased sphincter pressures (Browning and Parks, 1983; Miller et aL, 1988), lengthening of the anal canal (Browning and Parks, 1983; W omack et aL, 1988) and enhanced anal canal sensation (Miller et aL, 1988). Interestingly, results sim ilar to those following po st anal repair are achieved w ith anterior sphincter plication and levatorplasty (Miller et aL, 1989).
Patients w ho fail to benefit from these procedures form a difficult group to m anage. A repair can be repeated or, w here there has already been a posterior repair, an anterior repair can be perform ed. For p atien ts w ith very w eak sphincters, anterior and posterior repairs can be u n d ertak en sim ultaneously. These procedures can be technically difficult and m ay again be unsuccessful. Alternative approaches have been suggested. These include the construction of a neo-sphincter by transposition of the gracilis m uscle (Corman, 1985; W illiams
et aL, 1990) and the im plantation of an artificial sphincter based on a device used
in u rin a ry incontinence (C h ristian sen an d L o ren tzen , 1987). G racilis transposition has been com bined w ith prolonged neuro-stim ulation w ith the
effect of converting it from a fast twitch to a slow twitch muscle (Williams et aL,
1990). These techniques are still in their evolutionary phases b u t hold prom ise for the future.
WHY STUDY INTERNAL ANAL SPHINCTER SMOOTH MUSCLE