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). The latter is elliptical and engulfs the anal canal and internal sphincter, beyond which it terminates in a subcutaneous portion. The other two portions, the superficial and deep divisions, constitute a single muscular unit, which is continuous superiorly with the puborectalis and levator ani muscles. The external sphincter, bulbospongiosus, and transverse perineal muscles meet together centrally on the perineum and constitute the perineal body. The funnel-shaped configuration of the paired levator ani muscles form the major part of the pelvic floor and their fibers decussate medially with the contralateral side to fuse with the perineal body around the prostate or vagina.
Anal manometry confirms the extent of impairment of the internal and external sphincters by the resting and squeeze pressures, respectively. Manometry can also identify asymmetry, suggesting anatomic defects amenable to repair. Endoanal ultrasound has been recommended to detect occult defects and, in some centers with expertise, is considered more accurate than clinical or conventional methods of evaluation. Finally, electromyography of the pelvic floor can be used to differentiate between anatomic and neurogenic sources of incontinence, and pudendal nerve terminal motor latency testing can predict the likelihood of successful repair.
Biofeedback training focuses on strengthening of the anal musculature and improving anorectal sensation and is reported with variable success rates of approximately 75% for at least modest reduction in incontinence frequency, with 50% accomplishing complete continence. A bowel management program has been a successful approach for patients with anorectal malfunctions, Hirschsprung’s disease, and spina bifida. Of note, medical management can also be considered complementary to surgical therapy and may be carried out before and/or after surgery to optimize surgical results.
). Fecal diversion is not typically required for these repairs unless there are extenuating circumstances. The overlapping sphincteroplasty is associated with low rates of morbidity and mortality and reasonable rates of success with good to excellent results achieved in 55% to 68% of patients. Direct repair of anterior sphincter defects from obstetric injuries can be expected to restore fecal continence in 59% of patients. A study of 10-year outcomes after anal sphincter repair has suggested continued deterioration of function over time. For nonanatomic defects, postanal repair is advocated by some surgeons but reserved for highly select patients.
). Digital examination enables assessment of internal and external hemorrhoidal disease and anal canal tone and exclusion of other lesions, especially low rectal or anal canal neoplasms. Because almost all anorectal symptoms are ascribed to hemorrhoids by patients, it is essential that other anorectal pathologies be considered and excluded. Anoscopy is the definitive examination, but a flexible proctosigmoidoscopy should always be added to exclude proximal inflammation or neoplasia. Colonoscopy or barium enema should be added if the hemorrhoidal disease is unimpressive, the history is somewhat uncharacteristic, or the patient is older than 40 years or has risk factors for colon cancer, such as a family history. Depending on the degree of disease, treatment falls into two main categories, nonsurgical and hemorrhoidectomy.
