ABSTRACT
Anal incontinence is a socially crippling disorder. Soiling, the escape of flatus, or the inadvertent passage of stool are embarrassing situations few people can tolerate. It therefore behooves surgeons who care for these individuals to be familiar with any treatment options that might be available. Anal continence is dependent on a complex series of learned and reflex responses to colonic and rectal stimuli, and the considerable individual variation in bowel habits makes clear distinction of derangement of continence difficult. Normal continence depends on a number of factors: mental function, stool volume and consistency, colonic transit, rectal distensibility, anal sphincter function, anorectal sensation, and anorectal reflexes (1). The patient who has lost complete control of solid feces has complete incontinence. The patient who complains of inadvertent soiling or escape of liquid or flatus has partial incontinence. Less fastidious individuals may not complain of partial incontinence; therefore careful questioning of the patient may be necessary. In an effort to classify the severity of symptoms; Browning and Parks (2) proposed the following criteria: category A, those continent of solid and liquid stool and flatus (i.e., normal continence); B, those continent of solid and usually liquid stool but not flatus; C, acceptable continence of solid stool but no control over liquid stool or flatus; and D, continued fecal leakages. Numerous other grading scales exist. All these severity scores are simple to use. However, they mainly reflect sphincter function. The worse the function, the higher the score. Thus incontinence to solid stool is always considered worse than incontinence for liquid stool. This does not necessarily reflect the subjective experience of the patient. Furthermore, the reliability and validity of these grading scales are questionable. Because of these drawbacks and the lack of precision of the grading scales, they are no longer recommended as the sole method of categorizing patients and monitoring outcome of treatment (3). Some of the deficiencies of grading scales can be addressed by summary scales. These scales produce multilevel summative scores. The values for each type of incontinence are assigned according to the frequency of incontinent episodes. This frequency is one of the factors contributing to the severity of incontinence. Several scales also include items such as urgency, cleaning difficulties, the use of pads and lifestyle alterations. Numerous summary scales have been designed, such as those according to Rockwood, Jorge/Wexner, Pescatori, Vaizey, and many others. The assignment of values to types and frequencies of incontinence varies between scales. The frequently quoted Jorge/Wexner Continence score is outlined in Table 1 (4).
