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The true epidemiology of combined urinary and fecal incontinence is difficult to assess. The social stigma associated with these conditions has made it difficult for physicians to adequately identify affected patients. As we learn more about the function of the pelvic floor and recognize the common etiology of both anterior and posterior compartment dysfunction, we will offer better and more comprehensive care to our patients.

Sacral neuromodulation represents a promising therapy for patients with fecal incontinence. Overall, the published series demonstrate a high effectiveness, with a median of 90.8% success rates with minimal morbidity. The possibility of selecting patients on the basis of a preliminary peripheral nerve evaluation allows sacral neuromodulation a unique place in the spectrum of possible treatments for patients with fecal incontinence. The mechanism of action appears complex, with alterations in neuromodulatory reflex arcs and local neuropeptide expression. An improved understanding of these mechanisms will permit classification of the indications for this technique, which is likely to result in greater success.

The gynecologic indications for enterocele and rectocele repair are more numerous compared with the traditional colorectal indications because gynecologists primarily address vaginal symptoms when repairing a rectocele. Here, obstructive defecation symptoms are only some of a list of accepted indications. Preoperative evaluation typically only includes clinical assessment gained from the history and physical examination, and gynecologists rarely depend on defecography to plan a reconstructive procedure for rectoceles. Overall, surgical correction success rates are quite high when using a vaginal approach for rectocele correction. Vaginal dissection results in better visualization and access to the endopelvic fascia and levator musculature, which allows for a “firmer” anatomic correction. In addition, maintaining rectal mucosal integrity appears to reduce the risk of postoperative infection and fistula formation. More comprehensive data collection is necessary to better understand the effect of various surgical techniques on vaginal, sexual, and defecatory symptoms in these patients who may present with complex symptomatology where the rectocele and/or enterocele represent the dominant clinical finding.

Miraculous advances in surgical techniques have prevented countless patients from living with a permanent stoma after rectal resection or total proctocolectomy. When counseling patients preoperatively, it is important to communicate realistic functional expectations because surgery is not perfect and nearly all surgeries have some element of defecation dysfunction afterwards. Postoperatively, it is essential to work with patients to individualize treatment régimes. In turn, this will optimize their function and quality of life. Not every patient will achieve satisfactory results, and some will require a permanent stoma to improve their quality of life. When performing pelvic ileal pouches, awareness and counseling of the array of possible complications is necessary. Diligent evaluation when problems are suspected can frequently locate and treat the culprit. This is essential in order to prevent permanent problems in the pouch. Redo pouches are clearly feasible if the surgical expertise exists; therefore, this type of redo surgery should only be attempted by committed surgeons and motivated patients.

The main problem in assessing anal function in patients with a neoanal sphincter, particularly those after total anorectal reconstruction following Miles’ operation, is the onset of defecatory disturbance, which can sometimes be even more troublesome than anal incontinence. No QoL questionnaires have yet been drawn up for patients with obstructed defecation or combined functional disorders. There is a strong need for such a tool, which would make it possible to perform a better evaluation of the results of these newer operations and to compare different groups of patients undergoing different anal neosphincter procedures.

Bowel dysfunction in patients with neurologic disorders is common. The symptoms of constipation and fecal incontinence have a tremendous impact on the quality of life of these patients. In order to successfully manage patients with neurogenic bowel dysfunction, one should take into account the unique needs and condition of each patient, along with the patient’s lifestyle, level of activity, and social goals. Dietary modification and increased activity may be supplemented by pharmacologic agents. A scheduled and individualized bowel regimen is also important, and there are new treatment modalities that can improve the bowel function of these patients, as have been outlined in this chapter. Because of the complexity of the problems and the variability of symptoms, there is no hard data in terms of recommendations for managing these patients. The ideal bowel program for each individual often is achieved by trial and error. It is clear that meticulous attention to diet, hydration, use of bulk forming agents, exercise, and the selective use of stimulants remains a crucial part of bowel management in these cases. In refractory cases, the coloproctologist may give strong consideration to an intestinal stoma after appropriate patient and family counseling—a procedure that can be met with very satisfactory results and a normal quality of life in many cases.

A multidisciplinary team, which includes either a psychologist or a psychiatrist, should follow these specialized patients from their first visit to the final steps of their treatment and the definitive resolution of their problem using a “holistic approach.” The great advantage of a team psychologist—and a psychological perspective—in a dedicated coloproctology unit is in “flagging” patients who are likely, by virtue of their preexisting psychological and biosocial problems, not to benefit from surgery or to have symptom recidivism after surgery. Moreover, it is crucial that patients be afforded a range of non-surgical therapies for pelvic floor dysfunction as part of this holistic approach. The factors that are predictive for non-surgical success are still being evaluated in many units.