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Fecal incontinence is a socially disabling problem that is underestimated but widespread. Approximately 2% of the general population suffer from the inability to control bowel emptying [], and this rate rises with age: up to 11% of men and 26% of women over age 50 []. Its impact on society is substantial. Only a small portion of this population has to be treated surgically.

Faecal incontinence is a common but complex problem that can be difficult to treat successfully. Whereas some patients are helped by antidiarrhoeal drugs such as loperamide or codeine phosphate, this is a holding measure rather than a cure. Surgical treatments are limited, and some are complex with a high morbidity rate. The search for minimally invasive therapies continues. Sacral nerve stimulation is becoming the preferred option in many cases of internal and external anal sphincter dysfunction, but it is expensive and involves a two-stage procedure.

Radiofrequency energy delivery (Secca® procedure; Curon Medical) is a newer modality for treating fecal incontinence originally used for treating gastroesophageal reflux disease [], benign prostatic hyperplasia [], and joint-capsule laxity []. After being found a safe and effective means of strengthening tissues, its beneficial effects were first used within the anal canal in Mexico in 1999. Since then, demonstrated improvements have prompted further investigation, with promising results, for use within the anal canal. The radiofrequency generator produces heat by a high-frequency, alternating current that flows from two electrodes-active and dispersivecausing frictional movement of ions and tissue heating []. This procedure is not an option for obvious sphincter defects but can be used with a weak or thinned anal sphincter complex. Patients with a history of inflammatory bowel disease (IBD), extensive perianal disease, or chronic diarrhea should not be offered this treatment.

Fecal incontinence is a multifactorial disease. Anorectal physiology studies play an outstanding role in the evaluation of its etiology and severity, the two main factors that constitute the basis for the correct choice of treatment. However, the prognostic role of clinical factors and anorectal physiological tests in predicting the outcome to either conservative or surgical treatment is questionable.

The frequency of fecal incontinence (FI) in patients submitted to rectal resection (RR) for cancer ranges between 2% and 40% [1-6]. In fact, despite the significant improvements registered over the last few decades in the treatment of rectal cancer, not only in the control of the neoplasm itself and sparing of the anal sphincters but also in the preservation of urinary and sexual function [6-19], FI can occur, with severe detrimental effects on patients’ quality of life. In these patients, FI is a disabling clinical condition, the etiology of which is complex and not yet fully elucidated. It is regarded as a component of “anterior resection syndrome,” including an increased number of daily bowel movements, clustering, FI, and soiling after this operation [20-22]. In some cases, urinary incontinence also contributes to worsening of the clinical condition. Even if these patients are comforted by the fact that they have won their fight against the cancer, their personal and social life suffers considerably. Unfortunately, the minimalist attitude of some physicians prevents these patients from exploring the possibilities of treatment other than an appropriate diet or stimulating systems to empty the bowel completely.

Iatrogenic faecal incontinence can be split into two broad categories by aetiology. The largest group comprises patients undergoing proctological surgery for haemorrhoids, fissures, sepsis, rectoceles and local excision of rectal neoplasia. A second surgical group includes patients who have received anal instrumentation for the purpose of performing an anastomosis in the pelvis, most commonly by transanal insertion of a stapling device.

The term rectal prolapse can be associated with three different clinical entities: full-thickness rectal prolapse, mucosal prolapse and internal rectal intussusception. Full-thickness rectal prolapse is the most commonly recognised type and is defined as protrusion of the full thickness of the rectal wall through the anus. In mucosal prolapse, only the rectal mucosa protrudes from the anus. Internal intussusception may be a full thickness or a partial rectal-wall disorder, but the prolapsed tissue does not pass beyond the anal canal and does not pass out of the anus. This chapter focuses on full-thickness rectal prolapse with specific regard to associated faecal incontinence.

The term “sphincter atrophy” refers mostly to external anal sphincter (EAS) atrophy, as the EAS is the most important factor for maintaining fecal continence. EAS atrophy, often due to pudendal neuropathy caused by stretch injury during childbirth [] or chronic constipation [, ], is an important cause of fecal incontinence. When a woman is fecally incontinent and there is a history of a difficult childbirth with prolonged labor or chronic constipation as well as a sphincter rupture, there is always a chance that, besides the rupture, some atrophy is present in the EAS.

During the nineteenth century, at the current location of the famous Waldorf-Astoria Hotel in New York City, stood the first hospital in the world dedicated to the care of women with obstetric fistulas and complications []. By the end of that century, advances in obstetrics had dramatically decreased the severe complications of labor and delivery, and the hospital was closed. Currently, hospitals dedicated to the treatment of obstetric injury, particularly obstetric fistulas, exist in areas of the world that continue to struggle with the devastating effects of prolonged childbirth, obstructed labor, and maternal mortality [].

Data from the obstetrical literature show that about 0.4-3.7% of all vaginal deliveries result in a thirdor fourth-degree perineal laceration [, ]. Rarely, the reported incidence can go as high as 20–39% [, ]. When a third- or fourth-degree perineal laceration occurs during vaginal delivery, the standard repair is to approximate the torn ends of the anal sphincter using two to six interrupted mattress or figure-of-eight stitches and close the vaginal and perineal tissues in layers. Postpartum, the patient is typically put on a soft diet and given a stool softener for 7–10 days. This method of repair is described in the latest edition of [], the newest edition of [], and numerous other obstetrical textbooks.