Clinical and pathophysiologic studies were carried out in 29 patients with chronic diarrhea and incontinence. Most of these patients had been extensively investigated for diarrhea, whereas closer questioning revealed that the major (but previously unmentioned) problem was incontinence for liquid stools. Incontinent patients were, as a group, abnormal with regard to anal sphincter pressure, the ability to retain a solid sphere in the rectum as weights were applied, and the ability to retain saline that had been infused into the rectum. They were, however, no different from control subjects with regard to sphincter length and squeeze duration and with regard to the ability to detect the presence of fluid infused into the rectum. Estimation of sphincter tone by digital examination did not correlate with any objective measure of anal sphincter function or with continence to rectally infused saline. Analysis of the individual data from incontinent diarrhea patients showed that most of these patients had low stool volumes, low sphincter pressures, and an impaired ability to retain saline infused into the rectum. These results would be compatible with a defect in the function of the sphincter muscles. However, some patients had sphincter pressures well within the normal range, low stool volumes, and impaired saline continence. It seems likely that these patients have an abnormality in the continence mechanism other than a muscular weakness of the anal sphincter. Finally, 2 patients had sphincter pressures well within the normal range and good continence to saline, but passed very large amounts of -stool. Such patients probably represent a situation where large volume diarrhea overwhelms a fairly normal mechanism for preserving continence. Our results suggest that measurement of stool volume, sphincter pressure, and ability to retain rectally infused saline may aid in the diagnostic and therapeutic evaluation of patients with chronic diarrhea and fecal incontinence.
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