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PubMed2006

Randomized, controlled trial of anal electrical stimulation for fecal incontinence.

PURPOSE: Anal electric stimulation has been described as effective for fecal incontinence in several case series, but no study has addressed possible mechanism of benefit. We wished to examine whether anal electric stimulation, using an anal probe electrode, used on a daily basis at home for eight weeks, in the absence of any adjunctive exercises or advice, would improve symptoms of fecal incontinence and anal sphincter pressures when compared with "sham" electric stimulation. METHODS: Ninety patients (9 males, 81 females), with median age of 55 (range, 30-77) years were randomized, 47 to active anal stimulation at 35 Hz and 43 to "sham" stimulation at 1 Hz. Outcome measures included a one-week bowel diary, symptom questionnaire, manometry, and patients' evaluation of outcome. RESULTS: Seventy patients completed the study. On an intention-to-treat analysis, there was no difference between the two groups on any of the outcome measures after eight weeks. Of those who completed stimulation, 44 (63 percent) felt the stimulation had improved their continence. Those with intact anal sphincters were not likely to rate their change more positively than those with sphincter disruption (P=0.71). Median patient rating of bowel control increased from 3 of 10 before stimulation to 5 of 10 after stimulation (P=0.001). CONCLUSIONS: Eight weeks of anal electric stimulation was rated by patients as having improved their bowel control to a modest extent. There was no statistically significant difference detected between the groups, suggesting that 1 Hz was as effective as 35 Hz. This raises the possibility that the main effect is not sphincter contraction but sensitization of the patient to the anal area, or simply the effect of intervening per se. Home electric stimulation is a relatively cheap and generally well-tolerated therapy in the conservative treatment of fecal incontinence.

Adult↗
PubMed2006

Endoanal ultrasound findings and fecal incontinence symptoms in women with and without recognized anal sphincter tears.

OBJECTIVE: To estimate whether endoanal ultrasound findings are more prevalent in primiparous women with a history of anal sphincter tear than in women without this history and whether the findings are associated with fecal incontinence symptoms. METHODS: A total of 251 primiparous women at seven clinical sites underwent standardized ultrasound assessment of the internal and external anal sphincter 6-12 months after delivery. Participants were women in the three cohorts of the Childbirth and Pelvic Symptoms Study: 1) women with clinically evident third- or fourth-degree tear at vaginal delivery (n=106); 2) no tear at vaginal delivery (n=106); and 3) cesarean delivery without labor (n=39). Women completed the Fecal Incontinence Severity Index to assess fecal incontinence symptoms. RESULTS: Thirty-five percent of the sphincter tear group exhibited internal sphincter gaps compared with 3% of vaginal controls (odds ratio [OR] 18.4, 95% confidence interval [CI] 5.5-62.1) and 10% of cesarean controls. External sphincter gaps were identified in 51% of the tear group compared with 31% of vaginal controls (OR 2.3, 95% CI 1.3-4.0) and 28% of cesarean controls. In the tear group, fecal incontinence severity was greater in those with internal sphincter gaps compared with those with no internal sphincter gaps (Fecal Incontinence Severity Index score 6.6+/-8.3 compared with 3.3+/-6.1, P=.02), as well as in those with external sphincter gaps (6.1+/-8.4 compared with 2.7+/-5.0, P=.01), and greatest in those with both internal and external sphincter gaps compared with at least one gap not present (7.2+/-8.1 compared with 3.4+/-6.4, P=.003). CONCLUSION: Anal sphincter gaps detected by ultrasonography are prevalent in postpartum primiparous women with a history of sphincter tear and are associated with fecal incontinence severity. LEVEL OF EVIDENCE: II-2.

Adult↗
PubMed2005

Sacral nerve stimulation for fecal incontinence following surgery for rectal prolapse repair: a multicenter study.

PURPOSE: A proportion of patients have fecal incontinence secondary to a full-thickness rectal prolapse that fails to resolve following prolapse repair. This multicenter, prospective study assessed the use of sacral nerve stimulation for this indication. METHODS: Patients had to have more than or equal to four days with fecal incontinence per 21-day period more than one year after surgery. They had to have failed conservative treatment and have an intact external anal sphincter. RESULTS: Four female patients aged 42, 54, 68, and 65 years met the inclusion criteria. Three of the four patients had had more than one operation for recurrent full-thickness rectal prolapse before sacral nerve stimulation, one of whom had undergone a further operation for recurrence following stimulation. One patient had undergone one operation for prolapse repair. The preoperative duration of symptoms was ten, eight, three, and nine years, respectively. Although patients had an intact external anal sphincter, one patient had a fragmented internal anal sphincter. The frequency of fecal incontinent episodes changed from 11, 24.7, 5, and 8 per week at baseline to 0, 1.5, 5.5, and 1 per week at latest follow-up. Ability to defer defecation was also improved in two of three patients who had this documented. Fecal incontinence-specific quality of life assessment showed an improvement in all four domains. CONCLUSION: Sacral nerve stimulation should be considered for patients with ongoing fecal incontinence following full-thickness rectal prolapse repair if they prove resistant to conservative treatment.

Adult↗
PubMed1984

Anorectal sensorimotor dysfunction in fecal incontinence and diabetes mellitus. Modification with biofeedback therapy.

We studied anorectal sensory and motor function in 14 diabetics with fecal incontinence and compared the results with those in 13 continent diabetics, 31 nondiabetics with fecal incontinence, and 11 continent nondiabetics. The threshold volume at which diabetic patients with fecal incontinence experienced rectal sensation was higher (25.0 +/- 3.4 ml [mean +/- S.E.M.]) than that in continent diabetics (13.0 +/- 2.4 ml) or nondiabetics with or without incontinence (14.5 +/- 1.5 and 12.5 +/- 1.8 ml, respectively; P less than 0.02). Biofeedback conditioning in 11 incontinent diabetics led to normal sensory thresholds in six of seven patients with pretreatment thresholds above 20 ml; five of these six became continent. Biofeedback also improved external-sphincter function in nine diabetics, eight of whom became continent. Overall, 8 of 11 diabetics had a reduction in fecal soiling after biofeedback therapy. We conclude that fecal incontinence in diabetics may be caused by decreased rectal sensation or impaired function of the external sphincter or both, and that these abnormalities can often be improved by biofeedback therapy with resultant reestablishment of bowel control.

Adult↗
PubMed1991

[Prevalence of fecal incontinence and degree of information possessed by family physicians and health insurance].

Previous investigations have demonstrated that the prevalence of fecal incontinence ranges between 1.5 and 5% in the general population. It is, however, known that only a small portion of these patients consult a doctor for the complaints. To investigate the prevalence of fecal incontinence in Germany and to determine the reliability of epidemiological data from different sources, we distributed a questionnaire to healthy controls. In addition, two samples of patients were drawn from a local health insurance organization. Finally, the family physicians of incontinence patients from a specialized outpatient clinic which are covered by this health plan (AOK) were interviewed for whether they had noted the incontinence symptoms and had reported them to the health plan. It is shown that approximately 5% of people suffer from occasional incontinence, but that only 1.5% shown severe incontinence excluded fecal soiling. In patients with various disorders, the prevalence ranges between 0.2 and 0.35% according to health insurance data. However, in only about 75% of cases, the family physicians knew about the symptom, and in less than 50% of cases they had informed the health insurance. Epidemiological data, thus, contain a detection bias leading to an underestimation of the true prevalence of fecal incontinence.

Adult↗
PubMed1993

Biofeedback therapy for fecal incontinence after surgery for anorectal malformations: preliminary results.

Eight patients with fecal incontinence after surgery for anorectal malformations received one to four sessions of biofeedback therapy. The physiologic status of the anorectum before and after biofeedback therapy was investigated by anorectal manometry and electromyography of the external sphincter. The effectiveness of biofeedback treatment and the indications for its use in patients with fecal incontinence were investigated. Three of the four patients responded well to biofeedback therapy following three or four training sessions. However, in the other five patients who had only one or two sessions, a good response to the therapy was not obtained. Anorectal manometry and electromyography recordings of the external sphincter showed that biofeedback therapy improved voluntary sphincter function. The three good responders had an adequate and resting pressure both before and after biofeedback therapy and had good electrical activity of the external sphincter after therapy. In the presence of adequate resting and pressure, biofeedback therapy should be attempted for the treatment of fecal incontinence after correction of anorectal malformations before resorting to further surgical intervention. However, biofeedback therapy may not be suitable if the sphincters are markedly hypoplastic, or do not surround the anal canal after an inappropriate pull-through operation.

Anal Canal↗
PubMed1996

Spectrum of abnormal rectoanal reflex patterns in patients with fecal incontinence.

PURPOSE: Abnormalities of rectoanal inhibitory or excitatory reflex in patients with fecal incontinence are well described. A spectrum of abnormal responses, other than those already described in the literature, has been observed in some patients with fecal incontinence and forms the subject of this report. METHOD: Forty-three patients with idiopathic or traumatic fecal incontinence were studied to evaluate their reflex responses to balloon distention of the rectum, and results were compared with reflex responses of 29 control subjects with no anorectal complaints. RESULTS: Control subjects revealed normal reflex responses consisting of initial excitation followed by inhibition in the proximal anal canal and an excitatory response in the distal anal canal. Patients who were incontinent revealed five different types of reflex patterns. Eleven patients (25.5 percent) with segmental sphincter defects from obstetric injuries exhibited no distal excitation but had normal response in the proximal anal canal (Group 1). Eleven patients (25.5 percent) with idiopathic incontinence exhibited normal proximal response but an inhibitory as opposed to excitatory response in the distal anal canal (Group 2). Three patients (7 percent) with iatrogenic trauma failed to register an excitatory response in the proximal or distal anal canal but revealed a normal inhibitory reflex (Group 3). Nine patients (21 percent) with idiopathic incontinence revealed excitatory response in the entire anal canal but no inhibition (Group 4). Nine patients (21 percent) with idiopathic incontinence had a normal reflex pattern (Group 5). CONCLUSION: Excitatory and inhibitory components of rectoanal reflexes may selectively be abolished in neurogenic or traumatic insults to visceral and somatic anal sphincters, resulting in altered rectoanal reflex patterns.

Adult↗
PubMed2000

Fecal incontinence: a practical approach to evaluation and treatment.

Fecal incontinence is a common problem and can have a major impact on the quality of life of those affected. Various disease processes affecting stool consistency, rectal sensitivity, or the anal sphincters can cause fecal incontinence. Obstetric trauma is now known to be a major cause of sphincter dysfunction. The evaluation of the patient with incontinence helps to determine the choice of therapy-medical or surgical. The two most important tests are anorectal manometry, which provides information on sphincter pressures, and rectal sensation, and anal endosonography, which is currently the test of choice for defining the anatomy of the anal sphincters. The choice of therapy depends on the etiology of incontinence, the anatomy of the sphincters, and also on the effect of incontinence on the quality of life of the patient. Control of diarrhea, regardless of the cause, should be attempted first. Biofeedback therapy is effective in the majority of patients and is particularly attractive because it is safe and well tolerated. Surgery is offered when medical therapy is unsuccessful or when the etiology is thought to respond best to surgery, such as in postobstetric trauma. Sphincter repair, for treatment of selective sphincter defects, is the best surgical option. Neoanal sphincters and implanted artificial sphincters are far less attractive because of technical difficulties and low success rate.

Biofeedback, Psychology↗
PubMed2003

Artificial anal sphincter in severe fecal incontinence: outcome of prospective experience with 37 patients in one institution.

OBJECTIVE: To evaluate the outcome of artificial anal sphincter implantation for severe fecal incontinence in 37 consecutive patients operated on in a single institution from 1993 through 2001. SUMMARY BACKGROUND DATA: Implantation of an artificial anal sphincter is proposed in severe fecal incontinence when local treatment is unsuitable or has failed. The results of this technique have not been determined yet, and its place among the various operative procedures is still debated. METHODS: Artificial anal sphincters were implanted in 37 patients from 1993 through 2001. All patients had complete fecal incontinence and had failed to respond to medical treatment. Median duration of incontinence was 16 years. The causes of incontinence were sphincter disruption (19 patients), hereditary malformations (2 patients), and neurologic disease (16 patients). Six patients had had previous surgery for fecal incontinence. Assessment was made by physical examination (anal continence, rectal emptying) and anorectal manometry. RESULTS: In the first 12 patients, six devices had to be removed (50%); the cause of failure was found in all cases, and this allowed contraindications to be defined. Among the next 25 patients, 23 had an uncomplicated postoperative follow-up, and 5 developed seven complications: control pump change (n = 3), balloon migration (n = 1), and major rectal emptying difficulties in patients with obstructive internal rectal procidentia (n = 2). The artificial anal sphincter had to be removed definitively in three cases, representing the failure rate of this technique in the authors' experience (12%); two other devices had to be removed temporarily and the patients are awaiting reimplantation. In this latter group of 25 patients, 80% have an activated sphincter: continence for liquid stool is normal in 78.9%, continence for gas in 63.1%. Seven patients have rectal emptying difficulties, minor in five and major in two. Manometric studies showed mean pressures of 110 and 37 cm H(2)O with closed and open sphincter, respectively, with a mean duration of artificial sphincter opening of 128 seconds. CONCLUSIONS: The long-term functional outcome of artificial anal sphincter implantation for severe fecal incontinence is satisfactory; adequate sphincter function is recovered and the definitive removal rate is low. Good results are directly related to careful patient selection and appropriate surgical and perioperative management after a learning curve of the surgical team.

Adult↗
PubMed2007

Anterior anal sphincter repair for fecal incontinence: Good longterm results are possible.

BACKGROUND: Anterior anal sphincter repair (ASR) is standard treatment for fecal incontinence resulting from an obstetrically damaged anal sphincter. Longterm results of repair have generally been shown to be poor. This review of single-unit series aimed to determine longterm outcomes of primary ASR for patients with fecal incontinence from obstetrically damaged anal sphincter. STUDY DESIGN: This study included patients undergoing ASR from 1995 to 1999. We perform standard overlapping ASR, but external and internal sphincters are repaired separately. The internal sphincter is sutured by direct method and only if damaged. Telephone interview was conducted with all patients, after which questionnaires, including SF-36 survey, Fecal Incontinence Quality of Life Scale questions, and Wexner score-type questions, were sent at median followup of 7 years. Demographic data, anorectal physiology, and data on short-term followup (median 12 months) were prospectively collected. RESULTS: Sixty-four of 72 patients returned questionnaires and the operation was considered a success in 80% of patients at median followup of 84 months. Six patients underwent additional procedures for incontinence and 58 patients were analyzed. Fourteen patients reported complete continence to stool and flatus (20%). Continence had improved from median Wexner score of 14 to 7 (p < 0.001). Ninety-five percent of patients were satisfied with their operation. There was substantial improvement in all aspects of Fecal Incontinence Quality of Life Scale questionnaire and SF-36. None of the anorectal physiology variables were of value in predicting outcomes. CONCLUSIONS: We have shown that good longterm results can be achieved with anterior anal sphincter repair. The independent muscle repair technique could explain the improved outcomes.

Adult↗
PubMed2002

Long-term outcomes of pelvic floor exercise and biofeedback treatment for patients with fecal incontinence.

PURPOSE: The aim of this study was to assess the long-term clinical and quality of life outcomes for patients after referral to a four-month treatment program for fecal incontinence based on pelvic floor exercises and biofeedback. Secondary objectives were to document patients' subsequent treatment activities and their perception of the biofeedback training; to establish the long-term outcomes and initial predictors for the subset of patients who did not complete the treatment, or who failed to improve during the program; and to correlate changes in clinical outcome measures and quality of life over time. METHODS: Patients were contacted by telephone to determine their perception of progress subsequent to the treatment program, any subsequent treatment or activities relating to their fecal incontinence, and which aspect of the treatment program they believed was most helpful. St. Mark's and Pescatori fecal incontinence scores were also recorded, along with patients' self-assessments of their incontinence severity and quality of life. RESULTS: Eighty-three (69 percent) patients were contacted for interviews at a median of 42 (range, 26-56) months after program completion. At the time of follow-up, patients who completed the program continued to enjoy strongly significant improvements in all outcome measures, with 75 percent perceiving a symptomatic improvement and 83 percent reporting improved quality of life. For many patients, improvement continued subsequent to program completion. Patients whose incontinence scores became worse during treatment still reported improvement in their quality of life and perceived incontinence severity during the same time period; many experienced some degree of "catch-up" in their continence scores during the follow-up period. Fourteen patients (17 percent) went on to have surgery for fecal incontinence; of these, 6 (7 percent) had a stoma. Twenty (24 percent) regularly took antidiarrheal medication. Thirty program completers (41 percent) were continuing pelvic floor exercises. CONCLUSIONS: This study confirms the long-term improvement in fecal incontinence achieved through treatment with biofeedback and pelvic floor exercises. In this study, patients also continued to improve after treatment completion, possibly because of the strong emphasis placed on patients during treatment to continue the pelvic floor exercises on their own. The poor correlation between quality of life and quantitative scores of fecal incontinence suggests that there are important aspects of continence that are not being appropriately recognized.

Adult↗
PubMed1997

Clinical value of anorectal manometry index in neurogenic fecal incontinence.

PURPOSE: The present communication is an endeavor to assess the value of a simple motility index to separate patients with neurogenic or idiopathic fecal incontinence from those patients with the secondary form of the disease. METHODS: Study population consisted of 23 patients with idiopathic fecal incontinence and 13 patients with fecal incontinence secondary to surgical or obstetric trauma. They all had a standard anorectal manometric study after a 12-hour fast. A motility index was then prepared taking into consideration the peak sphincter pressure values, contractility endurance, and rectal sensory threshold. RESULTS: Despite differences in the mean peak squeeze pressure and sensory threshold between the two groups, there were significant overlaps for all parameters of standard anorectal manometry in both groups. However, patients with idiopathic incontinence had an index of smaller than 28, and the group with the secondary form of incontinence had indexes higher than 30. CONCLUSIONS: 1) None of the four parameters of a conventional anorectal manometry can accurately separate patients with neurogenic incontinence from those with secondary forms of the disorder. 2) The anorectal motility index presented here can accurately separate the two groups. 3) This index is superior to the standard anorectal manometry in evaluating patients with fecal incontinence.

Aged↗
PubMed1984

Fecal incontinence and the anorectal angle.

The role of the pelvic floor musculature was assessed in fecal incontinence by comparing the anorectal angle with the anal resting pressure. Twenty five patients were investigated; nine patients were incontinent. It appeared that a decrease in anal resting pressure was associated with an increase of the anorectal angle. In other words, impairment of fecal control was associated with a diminished activity of the pelvic floor musculature. In view of the fact that diminished anal sensation and anal pressure at maximal squeeze are found in fecal incontinence, it is probable that fecal incontinence is caused by pudendal nerve injury.

Anal Canal↗
PubMed2004

Pathophysiology of pediatric fecal incontinence.

This article addresses the diagnosis and treatment of pediatric fecal incontinence in 4 main categories: (1) Functional fecal retention, the withholding of feces because of fear of painful defecation, results in constipation and overflow soiling. Treatment includes dietary changes, use of laxatives, and cognitive and behavioral interventions such as toilet training, which diminishes phobia and provides positive reinforcement through a rewards system. (2) For functional nonretentive fecal soiling (encopresis), antidiarrheal agents can increase the consistency of stools and facilitate continence. Anorectal biofeedback for children has been proposed, but its efficacy remains unproven. Parents should be educated to conduct nonaccusatory toilet training and help children alleviate guilt and enhance self-esteem. Appropriately constructed trials are necessary to gauge the effect of adding prolonged use of enemas to an intensive toilet training program. (3) Surgery can correct minor congenital anorectal anomalies by identifying the external sphincter, separating the rectum from the genitourinary tract, and reconstructing the anus. However, there is great variation in postsurgical functional outcomes for anorectal malformations. Double-blinded, randomized controlled trials could help define the role of appendicostomy, cecostomy, sphincter reconstruction, colostomy, and artificial sphincters. (4) Children with spina bifida and fecal incontinence may benefit from techniques that teach them how to defecate. A continent appendicostomy (Malone procedure) is a promising treatment that completely cleanses the colon, increases the child's autonomy, and decreases the chance of soiling. A cecostomy can be performed surgically, endoscopically, or radiologically to provide some of the same benefits.

Child↗
PubMed2004

Patterns of fecal incontinence after anal surgery.

PURPOSE: Conservative anal surgery, with maximum preservation of the anal sphincters and continence, is becoming increasingly possible with the emergence of new sphincter-sparing treatments. Many surgeons remain skeptical, however, of the nature and impact of incontinence after anal surgery. We aimed to characterize the patterns of anal sphincter injury in patients with fecal incontinence after anal surgery. METHODS: We reviewed our fecal incontinence database and studied a subset developing incontinence after anal surgery. Maximum resting and squeeze pressures and the distal high-pressure zone to mid-anal canal resting pressure gradient were evaluated. Anal ultrasounds were evaluated and specific postoperative lesions were characterized. RESULTS: Patterns of sphincter injury in 93 patients with fecal incontinence after manual dilation, internal sphincterotomy, fistulotomy, and hemorrhoidectomy were studied. The internal sphincter was almost universally injured, in a pattern specific to the underlying procedure. One-third of patients had a related surgical external sphincter injury. Two-thirds of women had an unrelated obstetric external sphincter injury. The distal resting pressure was typically reduced, with reversal of the normal resting pressure gradient of the anal canal in 89 percent of patients. Maximum squeeze pressure was normal in 52 percent. CONCLUSION: Incontinence after anal surgery is characterized by the virtually universal presence of an internal sphincter injury, which is distal in the high-pressure zone, resulting in a reversal of the normal resting pressure gradient in the anal canal. These data support concerns that non-sphincter-sparing anal surgery leads to fecal incontinence and is increasingly difficult to justify given the availability of modern sphincter-sparing approaches.

Adult↗
PubMed1997

Fecal incontinence: three steps to successful management.

Fecal incontinence is a socially disruptive problem that occurs with increased frequency in older individuals. The causes of incontinence in this age group include abnormalities of rectal storage capacity, fecal impaction with overflow incontinence and disorders of rectosphincteric continence mechanisms. Evaluation consists of a careful history and physical examination, followed by studies of anorectal structure and function in selected patients. Therapeutic approaches include disimpaction and colonic cleansing, dietary modifications, pharmacologic agents, biofeedback techniques, and surgery. Most patients can be treated successfully with nonsurgical measures, with improvement in their quality of life.

Aged↗
PubMedDate not supplied

Use of biofeedback (BFB) in the treatment of fecal incontinence after surgical correction of anorectal malformations by posterior sagittal anorectoplasty (PSARP).

OBJECTIVE: To evaluate biofeedback (BFB) responses to rehabilitation techniques and physical exercises in incontinent or partially continent anorectal malformations patients after posterior sagital anorectoplasty (PSARP). DESIGN: Prospective study. SETTING: Pediatric Surgery-Department of Surgery-UNIFESP-EPM. PATIENTS: The authors report on 14 patients with anorectal malformations (4 with partial fecal incontinence after primary PSARP; 6 with fecal incontinence after primary PSARP; 3 with partial fecal incontinence after secondary PSARP; and 1 with fecal incontinence after secondary PSARP). All patients were rehabilitated via a BFB program of exercises in order to improve the function of the anal sphincteric muscular complex for a period of 1-3 years. MAIN OUTCOME MEASURE: Clinical and manometric control. RESULTS: After BFB, of 4 partially continent patients after primary PSARP, 3 became continent; of 6 incontinent patients after primary PSARP, 4 became continent; of 3 partially continent patients after secondary PSARP, 1 became continent, 1 showed no improvement and 1 became incontinent (infection + abscess + fibrosis + important anorectal stenosis). The incontinent patient after secondary PSARP showed no improvement. CONCLUSION: The authors concluded that BFB, used at the appropriate time with patient collaboration, is an important complement to the anatomical reconstruction of anorectal malformations in order to achieve good development and contractile functioning of the sphincteric muscular complex.

Adolescent↗
PubMed1997

Fecal incontinence in scleroderma. Clinical features, anorectal manometric findings, and their therapeutic implications.

Fecal incontinence is an under-reported complication of scleroderma. Ten incontinent patients with scleroderma were evaluated through anorectal manometry and compared with 20 incontinent patients without scleroderma who were matched for age and sex as controls. The scleroderma patients had a higher voluntary external anal squeeze pressure, whereas the resting internal anal sphincter pressure was similar to that of the control group. The threshold for rectal sensation in the scleroderma group was significantly less than that in controls. Episodes of fecal incontinence, anal canal length, and maximal tolerable volume were not significantly different between the study groups. The rectoanal inhibitory response was abnormal in 80% of patients with systemic sclerosis but was normal in 70% of the controls. Stool consistency was significantly looser in the scleroderma patients. Treatment of fecal incontinence in scleroderma patients may be successful in many patients using a combination of dietary and pharmacologic manipulation because diarrhea is an important etiologic cofactor superimposed on reduced internal anal sphincter pressure.

Adult↗