aCriteria fulfilled for the last 3 months From Drossman DA, Corazziari E, Talley NJ, et al., eds. Rome III: the functional gastrointestinal disorders. 3nd ed. McLean, VA: Degnon Associates, 2006:885–897, Appendix A, with permission.
Pitfalls for the Pelvic Floor Surgeon
It sometimes is easy to overlook or misinterpret signs and symptoms of constipation and defecatory dysfunction. Any acute change in bowel habits must be evaluated thoroughly, and malignancy must be considered in the differential diagnosis. Even in the presence of chronic disease, malignancy must still be excluded. Persistent symptoms after an empiric trial of medical therapy should prompt further evaluation, including colonoscopy or ﬂexible sigmoidoscopy. It is also possible to mistakenly attribute symptoms of defecatory dysfunction and constipation to pelvic organ prolapse when prolapse is actually the result of an underlying bowel disorder. In this case, surgical treatment of prolapse will have little lasting benefit if the underlying bowel disorder remains untreated.
History A thorough history and physical examination are critical to the evaluation of fecal incontinence and defecatory dysfunction. The history of present illness should focus on the bowel habits, including frequency and consistency of bowel movements (hard vs. soft, formed vs. unformed, diarrhea vs. constipation). Determining the duration and severity of symptoms, as well as exacerbating factors, is important for understanding the impact on quality of life. Patients should be questioned about straining with bowel movements, symptoms of incomplete emptying, and splinting of the perianal region, perineal body, or posterior vaginal wall to assist
Table 28.8 Functional Diarrhea
Loose (mushy) or watery stools without pain occurring in at least 75% of stools aCriteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis From Drossman DA, Corazziari E, Talley NJ, et al., eds. Rome III: the functional gastrointestinal disorders. 3nd ed. McLean, VA: Degnon Associates, 2006:885–897, Appendix A, with permission.
with evacuation. Patients should also be asked about the need to perform digital disimpaction because they are unlikely to volunteer this information. With respect to fecal incontinence, information should be obtained about leakage with solids, liquid, and ﬂatus and the ability to discriminate between these different types of stool (sampling). Similar to urinary incontinence, fecal incontinence can be stress related, urge related, or unconscious. Questions about alternating diarrhea and constipation, mucus or blood in the stools, constitutional symptoms, and changes in stool caliber can help the investigator uncover systemic and functional etiologies. Finally, it is important to ask about adaptive behaviors, incontinence product usage, and past and present treatments, including surgery, physical therapy, and medications.
A large amount of information can be obtained efficiently through questionnaires. Validated questionnaires quantify symptoms, which are subjective in nature, to objectively measure response to treatment. A valuable survey to assess defecatory dysfunction is the Colorectal-Anal Distress Inventory (CRADI), which has been incorporated into the Pelvic Floor Distress Inventory (PFDI) (80). The latter is a useful tool for evaluating symptoms of prolapse, urinary incontinence, fecal incontinence, voiding dysfunction, and defecatory dysfunction. Other useful symptom scales and bother scores for fecal incontinence include the Wexner Score, Fecal Incontinence Severity Index, and Fecal Incontinence Quality of Life Scale (81–83).