Ditching sophisticated tests for fecal incontinence. (History, Anal Exam May Suffice).

ST. LOUIS -- A thorough history and anal examination in a patient with fecal incontinence generally enables a surgeon to dispense with sophisticated diagnostic testing before proceeding to sphincteroplasty, according to speakers at the 12th International Pelvic Reconstructive and Vaginal Surgery Conference.

"If you can demonstrate that the sensations of the pelvic floor and the general function of the muscles are intact, then I don't think you necessarily need anything further before you move forward with your operation," said Dr. G. Rodney Meeks, professor of ob.gyn. at the University of Mississippi, Jackson, and president of the Society of Gynecologic Surgeons.

He saves endosonography, manometry, and electromyography for patients with prior failed repairs and for situations when he can't show reflexes or the patient has seemingly intact muscles that don't explain the symptoms.

The goal of the presurgical evaluation is to distinguish the patient whose fecal in-continence is due to anatomic disruption of anal sphincter integrity from the patient with pudendal nerve injury. Sphincteroplasty will help the former but not the latter. In patients with a combination of the two, surgical results are mixed.

Upon inspection of the anus, Dr. Meeks looks for the presence of the dove's tail sign: a partial absence of the rings of corrugation that normally encircle the anal sphincter. He checks to see if the patient can feel a light stroke of the pubic hair. When he touches the perineum, he looks for an "anal wink" in response: a tensing of the anus that indicates intact reflexes. A tensing of the pubococcygeus muscle when the clitoris is touched is also reassuring. Dr. Meeks also has the patient strain as if having a bowel movement; if she has a prolapse it will become evident.

The digital rectal exam is done both at rest and with the patient squeezing on the examining finger. It's quite easy to palpate the individual muscles and feel whether they are injured. The tone of the ...