Williams Gynecology, Second Edition (Schorge,Williams Gynecology), 2nd Edition

Anal Incontinence and Functional Anorectal Disorders

25–1. The definition of anal incontinence includes all EXCEPT which of the following?

a. Anal mucoid seepage

b. Incontinence to flatus

c. Incontinence to liquid

d. Incontinence to solid stool

25–2. Which of these statements regarding the epidemiology of anal incontinence in adults is true?

a. Anal incontinence prevalence decreases with age.

b. Anal incontinence is more common in men than in women.

c. There are wide variations in the estimated prevalence of anal incontinence.

d. Anal incontinence including flatal incontinence is uncommon, affecting fewer than 1 percent of community-dwelling adults.

25–3. Which of the following are required for normal defecation to occur?

a. Normal anorectal sensation

b. Competent anal sphincter complex

c. Adequate rectal capacity and compliance

d. All of the above

25–4. The anal sphincter complex includes all EXCEPT which of the following?

a. Puborectalis muscle

b. Pubococcygeus muscle

c. External anal sphincter

d. Internal anal sphincter

25–5. This image illustrates a physiologic contraction of pelvic floor muscles in response to increasing intraabdominal pressure. Paradoxical contraction of these muscles during defecation may cause which of the following?


Reproduced, with permission, from Corton MM: Anatomy. In Hoffman BL, Schorge JO, Schaffer JI, et al (eds): Williams Gynecology, 2nd ed. New York, McGraw-Hill, 2012, Figure 38-10B.

a. Anal incontinence

b. Anal mucoid seepage

c. Impaired evacuation

d. A greater (less obtuse) anorectal angle

25–6. Which of the following is true of the rectoanal inhibitory reflex?

a. Allows “sampling” of the rectum’s contents

b. Is mediated by the middle rectal branch of the pudendal nerve

c. Disappears in patients with cauda equina lesions or spinal cord transection

d. Involves transient relaxation of the external anal sphincter and contraction of the internal anal sphincter

25–7. Anorectal manometry allows assessment of all EXCEPT which of the following?

a. Anal reflexes

b. Rectal sensation

c. Rectal compliance

d. Electrical activity of muscles at rest and during contraction

25–8. Decreased perception of balloon insufflation during anorectal manometry

a. May indicate neuropathy

b. Occurs with decreased rectal compliance

c. Will likely occur with ulcerative or radiation proctitis

d. Indicates a rectal reservoir unable to appropriately store stool

25–9. This endoanal sonogram demonstrates which of the following?


Reproduced, with permission, from Bullard Dunn KM, Rothenberger DA: Colon, rectum, and anus. In Brunicardi FC, Andersen DK, Billiar TR, et al (eds): Schwartz’s Principles of Surgery, 9th ed. New York, McGraw-Hill, 2010, Figure 29-8.

a. Increased anorectal angle

b. Increased pudendal nerve motor latency

c. Disruption of the puborectalis muscle

d. Disruption of the external and internal anal sphincters

25–10. Compared with endoanal sonography, which of the following is true of magnetic resonance imaging?

a. Is less expensive

b. Allows better detection of external anal sphincter atrophy

c. Is more sensitive for detecting abnormalities of the internal anal sphincter

d. None of the above

25–11. Defecography may be helpful for the evaluation of which of the following?

a. Enteroceles

b. Intussusception

c. Internal rectal prolapse

d. All of the above

25–12. The angle measured in this image, which illustrates straining for defecation, is best captured using which test?


Reproduced, with permission, from Barrett KE, Barman SM, Boitano S, et al (eds): Gastrointestinal motility. In Ganong’s Review of Medical Physiology, 23rd ed. New York, McGraw-Hill, 2010, Figure 28-9B.

a. Defecography

b. Electromyography

c. Anorectal manometry

d. Pudendal nerve motor latency testing

25–13. Loperamide hydrochloride may be helpful for treatment of fecal incontinence by which of the following mechanisms?

a. Reducing stool volume

b. Increasing anal resting tone

c. Slowing fecal intestinal transit time

d. All of the above

25–14. Which of the following is true of agents such as methyl-cellulose and psyllium?

a. May cause abdominal distension and bloating

b. Improve bowel control via their anticholinergic properties

c. Increase the time available for the intestines to remove fluid from stool

d. All of the above

25–15. Which of the following anal incontinence treatment surgeries requires an implantable generator device to stimulate muscle?

a. Secca procedure

b. Artificial anal sphincter

c. Gracilis muscle transposition

d. Overlapping anal sphincteroplasty

25–16. Which of the following anal incontinence treatment surgeries uses temperature-controlled radiofrequency energy directed to the anal sphincter muscles?

a. Secca procedure

b. Sacral nerve stimulation

c. Gracilis muscle transposition

d. Overlapping anal sphincteroplasty

25–17. All EXCEPT which of the following are examples of functional anorectal disorders?

a. Proctalgia fugax

b. Dyssynergic defecation

c. External anal sphincter defect

d. Inadequate defecatory propulsion

25–18. Functional fecal incontinence may be due to which of the following?

a. Poor rectal compliance

b. Abnormal intestinal motility

c. Weakened pelvic floor muscles

d. All of the above

25–19. A 37-year-old G3P3 woman presents to her gynecologist at the time of her annual examination with complaints of severe anal pain every few months that is incapacitating but lasts only approximately 2 minutes. After exclusion of organic pathology, this condition is best managed how?

a. Reassurance

b. Secca procedure

c. Opioid analgesics

d. Sacral nerve stimulation

25–20. Which of the following is true of dyssynergic defecation?

a. Is associated with mucoid seepage and anal incontinence

b. May be confirmed by anorectal manometry or electromyography

c. Accounts for less than 5 percent of cases of chronic constipation

d. May be treated with diphenoxylate hydrochloride or loperamide hydrochloride

25–21. What is the most common rectovaginal fistula location?

a. High (the upper third of the vaginal wall)

b. Mid (the middle third of the vaginal wall)

c. Low (the distal third of the vaginal wall)

d. These three occur with approximately equivalent frequency.

25–22. In addition to developing as an obstetric complication, rectovaginal fistula may be associated with which of the following?

a. Coital trauma

b. Cervical cancer

c. Tuberculosis infection

d. All of the above

25–23. All EXCEPT which of the following may aid in diagnosis of a rectovaginal fistula?

a. Vaginoscopy

b. Barium enema

c. Noncontrast computed tomography

d. Tampon in the vagina with methylene blue instilled in the rectum

25–24. The rectovaginal fistula repair depicted here is which of the following?


Reproduced, with permission, from Schaffer JI, Hoffman BL: Surgeries for female pelvic reconstruction. In Schorge JO, Schaffer JI, Halvorson LM, et al (eds): Williams Gynecology, 1st ed. New York, McGraw-Hill, 2008, Figure 42-26.4.

a. Transanal episioproctotomy

b. Endorectal flap advancement

c. Transvaginal episioproctotomy

d. Fistulotomy with tension-free layered closure

25–25. All EXCEPT which of the following are true statements regarding surgical repair of rectovaginal fistulas?

a. Success of repair after obstetrical injury is usually very good: 78 to 100 percent.

b. Generally, successful repair rates are highest with the first surgical attempt.

c. Surgical repair should be delayed until surrounding tissues are free of edema and infection.

d. Fistulas in the midvagina commonly are repaired by a transabdominal approach using bowel resection and primary reanastomosis.

Chapter 25 ANSWER KEY