Key Concept: A thorough examination involves evaluation of everything from the undergarments and perineal skin to the perineum, including both rectal and vaginal examinations, and abdomen. Validated scoring systems will assist in quantifying and tracking progress.

The physical examination focuses generally on the abdomen and perineum. The abdominal exam generally keys on scars, masses, distension, and tenderness. When looking at the perineum, I first note the underclothes and perianal skin for any signs of soilage, along with any skin irritation (Fig. 13.2) or anal scars over the perineal body or over the anal skin. I typically examine patients in the left lateral position. In women I look in the vagina and note, with strain, any descent of the vaginal wall. I may also digitize the vagina again to clarify vaginal descent or simultaneously digitate the anus and vagina to again clarify descent. I ask them to strain and also note anal descent. When I see that the anal area move 4–5 cm and take on the shape of a bowel, this may be associated with damaged support structures, straining, and defecation problems. While there are patients that have descent and no defecation issues, it is something to keep in mind in combination with the history as clues to the etiology of the fecal incontinence. These patients may not be totally emptying their rectum or have an element of internal prolapse that may be adding to their symptoms. The anal and perianal skin requires close inspection first looking at the length of the perineal body. I ask them to squeeze and look for anal muscle movement. Many times there is excessive buttock movement as patients have gotten into the habit of squeezing all muscles in that region in an effort to avoid the horrifying aftermath of fecal leakage. To determine if they can contract their anal muscle, touching the skin over the anal muscle and asking them to pull only that muscle toward their umbilical area will clarify for them the muscle to contract and allow you to detect anal sphincter movement. On digital anal exam, differentiating between movement of the levator muscle and anal sphincter when squeezing should be noted, as you may be falsely believe the patient has sphincter tone when in fact is coming from higher in the canal. Again asking them to pull the muscle to their umbilical area may assist in detecting anal sphincter movement. Also important is anal muscle fatigue, which may be detected after several prolonged (about 15 s) anal sphincter contractions. For patients with significant fatigue, anal muscle retraining and strengthening is strongly considered as part of the treatment plan. On digital anal exam, a mass, the stool content (and character), presence of a rectocele, and abdominal contents that impinge on the rectum with strain should also be considered. An anoproctoscopy is helpful if there is suspicion of a mass or proctitis.

Quantitative tools of evaluation such as incontinence scores and quality of life scales may be employed. They are helpful when looking for improvement or change after a treatment intervention. However, they should never replace a comprehensive history. Some form of incontinence tool is mandatory to determine using sacral nerve stimulation, which will be discussed in more detail below. As there are many acceptable tools used for the purpose of fecal incontinence, choosing one that works for you and your office staff and administering the questionnaires before seeing the patient and after treatment interventions will allow familiarity with its nuances and use. One study looked at the current popular tools to score fecal incontinence (Rothenberger, Wexner, Vaizey, and Fecal Incontinence Severity Index) and found the Wexner scale correlated most closely with subjective perception of severity of symptoms by patients [5]. Another study looked at “responsiveness and interpretability” of the Vaizey score, Wexner score, and Fecal Incontinence Quality of Life scale [6]. These researchers felt none of these popular tools attain the high levels of psychometric soundness needed to be recommended as the best tool to use. They also echo the notion previously stated, that what a patient views as important may be different from the physician. While the Wexner score was felt to be the most suitable for severity assessment, they recommended that several tools should be used for evaluation in an attempt to circumvent these issues. An overview of each tool and its pros and cons are beyond the scope of this paper, but an excellent overview was written by Wang and Varma [7], which outlines some of the commonly used tools.

Key Concept: Testing is meant to augment or clarify findings on history and physical examination. Ultrasonography is my preferential test to help guide therapy.

Testing is individualized based on the history and physical exam. In appropriate patients, a colonoscopy would be ordered. In some patients where I question their ability to control stool, a fiber enema is administered (Fig. 13.3). This consists of fiber (i.e., a packet or large tablespoon of Metamucil^R, Citrucel) that is poured into an empty container and mixed with about 50 cc of water and quickly instilled in the rectum before it has time to gel. Then the patient walks around, bends over, and generally has sustained non-strenuous activity for 5 min to determine if they have leakage of this mixture from their anus.

The utility of anorectal physiology testing was questioned by our center and found not to correlate with incontinence scores [8]. Also ultrasound findings did not correlate with manometry results. We felt that preoperative anal manometry and endoanal ultrasound should be used to guide treatment, but improvement after an overlapping sphincter repair should not be assessed by changes in manometry pressures. This somewhat contradicts data from another unit; however, their aim was somewhat different. They looked at whether anal manometry could separate those patients with fecal incontinence from healthy individuals [9]. They found that patients with fecal incontinence had lower rest and squeeze pressures and lower urge sensation along with a higher volume of first sensation pressures. Overall they found that single studies were not helpful, but the entire panel of anal physiology studies had excellent sensitivity, moderate specificity, and convincing accuracy.

My feeling is that overall anal physiology testing may guide therapy, but I am not sure it is always needed. We rarely order needle EMG looking for neurological damage as it has not proved useful in guiding treatment. Perhaps looking for a sacral reflex before considering sacral nerve stimulation may be a consideration. I am also not sure that pudendal nerve terminal motor latency offers much assistance. Previously we used nerve prolongation, particularly bilaterally, to counsel patients that results after sphincter repair most likely would be poor. However, I have seen patients without prolongation of their pudendal nerves when tested, where absolutely no anal muscle moves when I ask them to squeeze on physical exam. Anal endosonography on the other hand provides a useful road map when considering treatment, and I usually rely on this test (making sure I perform it myself or know that the endosonographer is experienced in accurately depicting sphincter defects). Our unit still typically orders anorectal physiology on most patients because we maintain extensive databases that we may use in future studies; however, we only use the data to selectively counsel patients. For instance, a patient with a low maximal tolerated volume and low anal pressures may not achieve the expected short-term benefit from an overlapping sphincter repair. We would use this information to preoperatively discuss expected outcomes with the patient and aid in navigating the treatment plan. While pelvic magnetic resonance imaging is a consideration instead of or with anal endosonography, I am not convinced it adds enough information to justify the expense. I do not routinely order a defecating proctogram unless there is an accompanying problem with stool expulsion during defecation. Dudding and Vaizey wrote an excellent overview of testing for fecal incontinence and other pelvic floor disorders, and the reader is directed to this review for more in-depth descriptions of the various tests [10].

Key Concept: From the very beginning, set realistic expectations with your patient and ensure they understand this may involve several different treatment modalities.

The next step in management involves an individual treatment plan for the patient. This does not encompass only one intervention, but could involve several combined modalities customized for the patient and revolves around a clear understanding of the pathophysiology and underlying conditions. Fecal incontinence should be viewed as a chronic disease like diabetes or hypertension. Similarly, in these chronic diseases, several treatment modalities may be needed for optimal control of the disease process and optimization of the patient’s quality of life. Similarly management of fecal incontinence is a long-term notion, and adjustment in the treatment plan will be necessary as needed. This also involves setting realistic expectations for the patient and the surgeon (i.e., some health-care provider must be prepared to assist and manage this patient long term). Society typically views defecation issues as voluntary (i.e., mind over matter) which adds to unrealistic goals determined by the patient. Therefore, attaining “perfect” bowel function may not be a realistic goal, and the health-care provider should emphasize improvement and improvement in quality of life as the goals.