A prospective evaluation of the value of anorectal physiology in the management of fecal incontinence

PURPOSE: This study was designed to determine whether anorectal physiology testing significantly altered patient management in the setting of fecal in continence. METHODS: Patients referred to the anorectal physiology laborato ry for evaluation of fecal incontinence were prospectively interviewed and examined by a colon and rectal surgeon. A decision to treat either medicall y or surgically was reached. The patients underwent physiologic testing wit h transanal ultrasound, pudendal nerve terminal motor latency, and anorecta l manometry. A panel of board-certified colon and rectal surgeons then revi ewed the history and physical examination, as well as the anorectal physiol ogy tests, of each patient and reached a consensus on management. Managemen t plans before and after physiologic evaluation were compared. RESULTS: Nin ety patients (6 males) were entered into the study. The patients were divid ed in two groups: those with pretest medical management plans (n = 45) and those with pretest surgical management plans (n = 45). A change in manageme nt was noted in nine patients (10 percent). In the medical management group , the management changed from medical to surgical therapy in five patients. Transanal ultrasound detected anal sphincter defects in all patients who c hanged from medical to surgical management but in only 10 percent of those who remained under medical management (P = 0.0001). In the surgical managem ent group, three patients (7 percent) changed from surgical to medical ther apy and one patient (2 percent) changed from sphincteroplasty to neosphinct er. Transanal ultrasound detected a limited anal sphincter defect in one pa tient (33 percent) who changed from surgical to medical management and a si gnificant defect in all 41 patients (100 percent) who remained under surgic al management (P = 0.003). CONCLUSIONS: Anorectal physiology testing is use ful in the evaluation of patients with fecal incontinence. Without the info rmation obtained from physiologic testing, 11 percent of patients who may h ave benefited from surgery would not have been given this option, and 7 per cent of patients could have potentially undergone unnecessary surgery. Tran sanal ultrasound is the study most likely to change a patient's management plan.