Patients with high openings, posterior openings, or fistula extensions are at risk to develop continence disorders after anal fistulotomy.

In order to assess fistulography for anal fistula, 25 fistulograms were reviewed. The results as for extensions and internal openings were compared with the surgical findings. Fistulograms were correct in only 16 percent. False-positive results occurred in 10 percent. Fistulography is inaccurate and unreliable.

Selection of the best surgical procedure for the treatment of complete rectal prolapse is difficult amid the many different techniques for which excellent results are reported. A critical review is given. It is concluded that any surgical procedure with rectal mobilization and fixation as a standard maneuver will lead to a recurrence rate of 2% to 4%. Advocacy of additional maneuvers to make the procedure easier is acceptable if it does not lead to a higher complication rate. But to obtain a better result its benefit has to be proven, either by a large prospective double-blind study, or by tests from the colorectal laboratory. New surgical techniques for rectal prolapse should therefore be based, not only on a low recurrence and complication rate, but also on tests that evaluate the effect of the procedure on fecal continence.

The spastic pelvic floor syndrome is a functional disorder based on contraction instead of relaxation of the pelvic floor muscle during straining, which inhibits defecation and gives rise to constipation. Until now no adequate treatment has been found for this condition. The treatment described here is aimed at teaching patients to relax their pelvic floor muscle during straining. Treatment consists of a training program with EMG feedback, followed by simulation of the defecation process, using oatmeal porridge. Patients are then given instructions to generalize the relaxation response in their daily lives. Treatment was completely successful in seven of ten patients. The three remaining patients learned to strain in the correct manner, but could not achieve generalization. Two of them underwent subtotal colectomy because of delayed colonic transit times, which subsequently resulted in normal evacuation. In the third patient, the generalization was most likely hampered by psychologic problems, for which she now receives psychotherapy.

In 12 patients with constipation, it was detected by defecography that, during straining, the anorectal angle did not increase, but remained at 90 degrees. These patients were unable to excrete barium. Since the anorectal angle is a measure of activity of the pelvic floor musculature, a dysfunction of this muscle was suspected. In order to determine whether this abnormality represented a true functional disorder or just a voluntary contraction of the pelvic floor muscles due to embarrassment, we performed electromyographic, manometric, and transit time studies in these patients. The electromyographic studies confirmed the persistent contraction during defecation straining. Both manometry and electromyography revealed normal muscle function at rest and during squeezing. Colonic transit time studies demonstrated rectal retention in nine of 12 patients, indicating outlet obstruction. Persistent contraction of the pelvic floor muscles, for which we propose the name "spastic pelvic floor syndrome," represents a functional disorder of normal pelvic floor muscles, causing a functional outlet obstruction.