Fecal incontinence after pelvic surgery is difficult to quantify as there as many facets included in the term FI. These include urgency, leakage of mucous, leakage of liquid stool, difficulty with control of solid stool and frank loss of an entire bowel motion. Additionally disturbances in frequency of defecation including multiple small stools in a short span of time are sometimes included in this definition by researchers. This lack of clarity leads to the wide range reported in the literature. FI after rectal cancer resection is reported to range from 0 to 71 % [1–4]. This also includes patients that have undergone radiotherapy, and the contribution for that element of the treatment plan also is unclear. FI has also been reported in a significant number of gynecological and urological cancer patients after they have undergone pelvic surgery with or without radiation.

Previously, it was believed that FI after pelvic surgery, especially after rectal cancer resection, was a transient phenomenon, where patients reverted back to “normal” or at least acceptable defecation by 6–12 months after surgery [5–7]. However, several long-term studies have reported the sustained presence of FI and other disabling defecatory symptoms well beyond 12 months [1–3]. This data supports the concept that FI after pelvic surgery likely results from permanent changes rather than just temporary dysfunction in the early postoperative period. Permanent defecation dysfunction imparts a profoundly negative impact on patient’s lives with a significant decrease in measures of quality of life and overall mental health status [4, 8]. Initially research efforts focused on cancer cure without appreciable attention to quality of life factors. With the widespread availability of validated tools to quantify and document effects of surgical treatment on quality of life, these tools should be routinely administered and incorporated into the treatment regime of these complex surgical patients [4, 9].

As awareness grew that FI could be a permanent problem after surgical treatment of pelvic malignancies, considerable investigational research to elicit the mechanism leading to this problem have been conducted over the past several decades [1–7]. Several anatomical and physiological abnormalities have been defined. However since the act of defecation is so complex, in-depth understanding of the multifactorial nature of this problems is not completely understood [4, 10]. Many factors have been shown to contribute to FI such as anal sphincter damage, loss of a rectal reservoir, damage to the autonomic nerves, as well as the possible negative consequences of radiotherapy. As a result of this multifaceted etiological picture, no single treatment exists to manage and treat FI after pelvic cancer surgery and thus, a tailored approach for each patient is mandated.

Over the past several decades, the technical ability to perform sphincter-saving operations has become increasingly utilized for treating low rectal cancers. It has been estimated that approximately 80 % of rectal cancer patients can undergo a sphincter-sparing operation [4]. Advances in surgical technique such as awareness of the importance of total mesorectal excision (TME) for low rectal cancers have helped improve survival from rectal cancer. Improvement in survival has also been aided by factors beyond surgical technique such as campaigns targeting earlier diagnosis along with advances in radiotherapy. However, with the increased ability to perform very low colorectal or coloanal anastomoses coupled with increased survival, the risk of FI after surgery is increasingly evident. It is now accepted that up to 90 % of these patients will subsequently have a change in bowel habits, ranging from increased bowel frequency and evacuatory dysfunction to FI [4, 11–13]. These dysfunctional symptoms after low rectal resection vary considerably between patients and have been collectively termed the anterior resection syndrome. The anterior resection syndrome can be characterized by increased bowel frequency, erratic defecatory patterns, rectal urgency, clustering of stools (multiple small stools in a short span of time), tenesmus, obstructed defecation and FI [3, 6, 11]. More simply stated—anterior resection syndrome is disordered bowel function after rectal resection leading to a decreased quality of life [4]. This syndrome is incompletely understood, and is attributed to a loss of the rectal reservoir. There may also be additional effects from direct damage to the anal sphincters and injury to the autonomic nerves. For example, neurological or direct physical damage to internal anal sphincter can result in decreased anal resting pressure, which may or may not recover over time [2, 8] with a resultant loss of the rectoanal inhibitory reflex (RAIR) in over 60 % of patients [14]. It is speculated that this could contribute to passive incontinence of stool. Damage to the striated external sphincter muscle can be manifested by decreased squeeze pressures and this could be mediated by nerve plexus injury during pelvic dissection and rectal mobilization. Additionally, during mobilization of the sigmoid and rectum, especially when dissecting around the inferior mesenteric artery, the parasympathetic pelvic splanchnic nerves may become damaged. This could result in a denervated colonic segment with an increased transit time and a greater number of nonpropagating contractions. This combination could lead to increased transit of the fecal bolus in the remaining left colon with in turn could cause severe fecal urgency and possibly incontinence [15].

By definition, various amounts of rectum are removed during a low anterior resection with a subsequent loss of rectal capacity. There is an intuitive belief that the more rectum left in situ, the better the postoperative bowel function. Studies have been designed to look at the resultant effect that rectal stump length has on function. Many have shown that a low anastomosis, 6–8 cm from the anal verge, gives patients significantly more problems with FI postoperatively [16, 17]. Not all studies found this conclusion. Jehle et al. reported on a series of 55 patients where they found that the level of the colorectal or coloanal anastomosis had no correlation with post operative continence. Their data showed that FI was directly related to sphincter damage and autonomic nerve injury [18].

However there are still surgeons who feel that a decreased rectal reservoir is an important contributing factor for rectal urgency and incontinence. This has led these researchers to examine ways to develop an alternative neorectal construction, such as the colonic J pouch, transverse coloplasty, and a side-to-end anastomosis. Studies looking at the colonic J pouch have shown that it decreases bowel frequency up to 1 year after surgery. However comparing this to a traditional straight anastomosis, at 2 years stool frequency was the same in both groups [19–22]. A natural further question is whether the anticipated improvement in quality of life for the first and possibly 2 years after reconstruction with a colonic J pouch should make surgeons consider constructing a colonic J pouch when feasible for all low pelvic anastomosis. This also remains an unsettled question.

Construction of a colonic J pouch can lead to new problems with expulsion of stool. The only settled controversy is that the limbs of the colonic J pouch should be from 6 to 8 cm. Outside of this, the effect that volume of the neorectum has on influencing fecal continence and urgency and the way it should be constructed remains unclear. No overwhelming benefit between colonic J pouch and a side-to-end (side of proximal colon to end of rectal stump) anastomosis has shown superior results [4, 23]. Our institution currently has ongoing studies to determine if either the colonic J or side-to -end anastomosis is superior. We know that about 25 % of patients cannot have a colonic J pouch due to problems with reach or a fatty pouch that will not fit into a narrow (particularly male) pelvis [24]. We still feel there is benefit to a neo reservoir and therefore attempt to construct either a colonic J pouch or side-to-end anastomosis when feasible in patients not enrolled in this study.

In conclusion, any of these changes mentioned above either in combination or as a sole contributor could lead to significant defecatory dysfunction. The exact role played by nerve disturbance, sphincter damage, or decreased rectal reservoir will require further study.

Hysterectomy for both benign and malignant conditions is the most widely performed major gynecological operation in the United States with up to 40 % of the female population undergoing this operation by the sixth decade of life [25]. Both bladder and bowel abnormalities have been reported after this operation with long-term bladder impairment occurring in 30–75 % of patients [26, 27]. Bowel dysfunction, on the other hand, has mostly been reported to be constipation and irritable bowel-like symptoms [25, 28–33]. The bladder and bowel dysfunction after hysterectomy may be related to the disruption of the autonomic nerve fibers that are carried in the pelvic plexus. These sympathetic and parasympathetic nerve fibers run in the cardinal and uterosacral ligaments. During dissection of parametrial tissue and division of the uterosacral ligaments, injury may occur.

Very few studies have looked at FI and anorectal dysfunction after hysterectomy [28, 34]. Sood et al. studied anorectal dysfunction after radial hysterectomy for cervical cancer in 11 patients [34]. They performed manometry, balloon defecation, and pudendal nerve latency testing in both the preoperative period and 6-months postoperatively. They found significantly lower resting and squeeze pressures at 6 months after surgery, bilaterally impaired pudendal nerve latency as well as decreased self reported quality of life. Similarly, Altman and colleagues reported on 76 patients undergoing hysterectomy and concluded that patients had an increased risk of mild to moderate anal incontinence after hysterectomy and that adding a bilateral salpingo-oophorectomy substantially increased such risk [28]. Therefore, gynecological surgeons should be mindful of this possibility when counseling patients for both benign and cancer related hysterectomy.

Prostatectomy, whether performed though the perineum or through a retropubic approach, carries a risk of bowel-related symptoms, including FI, as shown in several studies [35–38]. Bishoff and colleagues [35] reported on their experience with perineal and retropubic prostatectomy and found FI rates between 15 and 18 %. Likewise, Ruiz-Deya et al. [38] reported a 7 % rate of new FI after perineal prostatectomy. The etiology of FI from a perineal approach may include direct damage to the rectum and anal sphincters while the retropubic approach likely causes damage to the autonomic nerves. Again urological surgeons need to be aware of this possible postoperative problem in order to give accurate preoperative counseling.

Radiotherapy for anal, rectal, cervical, uterine, bladder and prostate cancers is often used as primary or adjuvant therapy. Whether the delivery method is internal or external beam or brachytherapy, all radiation has possible destructive effects on anorectal structures as well as the potential to cause neuropathy to the autonomic pelvic nerves. Multiple studies have demonstrated direct anorectal dysfunction from radiation therapy which in turn leads to the possibility of FI, especially if administered after a low anterior resection [39–44]. In a cadaveric study, Wallner and colleagues studied the effects of radiation after low anterior resection with TME and found that radiation decreased the compliance of the residual rectal remnant due to fibrosis. There also was likely disruption of the myenteric plexus of the internal anal sphincter, compromising the RAIR and affecting anal pressures [40].

Currently there is limited modern prospective data on the effect radiation therapy may have on FI, especially in regards to rectal resection. Interestingly, most of the published series use data from previous decades when enhanced radiotherapy techniques were not available/utilized. Further research utilizing modern radiation therapy techniques is needed. Ideally these studies would utilize tools to evaluate bowel and anal function before and after radiation is administered. The additive effects of rectal resection would also need to be factored into a study such as this.

Currently, there are no standard treatment algorithms for helping patients that suffer with FI after pelvic cancer surgery. Any therapeutic approach should be based on the suspicion of a sphincter lesion, confirmed or suspected nerve lesions, or the influence of any radiotherapy. Concurrent urinary incontinence should also be taken into consideration as well. All treatments that are currently available are purely empirical and symptom-based [4]. These various therapies are similar to the existing treatments that are utilized for fecal incontinence and other rectal evacuatory disorders. Treatments modalities can be broadly divided into nonoperative and operative management. Treatment should be individualized and based on the severity of the patient’s symptoms, the patient’s overall condition, history of radiotherapy and the degree to which the incontinence is affecting the patient’s quality of life [44]. It should be emphasized again that most of these treatments are lacking any randomized, placebo-controlled trials and are still investigational with needed and anticipated ongoing research.