Fecal incontinence: indications for repairing the anal sphincter.

Incontinent patients should be comprehensively investigated by objective tests, especially manometry, continence tests, and electromyography. Manometry can be used to predict the functional outcome and to calibrate the sphincter repair. Pure anatomical defects of the anal and pelvic musculature deserve surgical correction with or without overlapping the muscle ends. If the repair is delayed it should be done after a 3 month interval. A protective colostomy has to be performed in complex cases and in cases with septic complications. Before closing the colostomy, the ano-rectal function should be assessed. Acceptable continence can be restored in the majority of the patients, the outcome depending on the extent of local defects and the severity of concomitant pelvic floor neuropathy. Skeletal muscle transposition remains an esoteric approach to be used only in selected patients; the implantation of a neuromuscular stimulator seems to be warranted. In the presence of important functional deficits, sphincter repair may create a situation where additional conservative measures become more effective. A post-anal repair may be considered 3-12 months after rectopexy or sphincter repair. Incontinence based on pure functional defects is initially treated conservatively. A post-anal repair may improve the situation in two thirds of the patients but fails to help those who need it most. Failure seems to be related to a continuing neuropathic process. A peri-anal prosthetic band implant may be a valuable alternative in such patients. A sigmoidostomy is a measure of last resort. The prevention of fecal incontinence is most important and concerns surgeons, obstetricians, and physicians.