So, in terms of colonoscopy, today it's important to do a colonoscopy in your patient who is above the age now of 45, right? And so they may have an increased risk of colon cancer. And what you want to do is, reflected in this image here, is, well, A, do a rectal exam. That's number one. But also, in endoscopy, sometimes you can see a mass that's infiltrating that neuromuscular bundle right at this anal canal and that sphincter, and that may be triggering incontinence. So that is very important. And then also allows you to get random biopsies in your patients who have diarrhea. And of course, someone who is coming in with bleeding and other alarm symptoms, you want to go to endoscopy for them. Also allows you to look at the mucosidum to make sure there's no proctitis or even radiation injury in someone who has had radiation for prostate cancer or cervical cancer. And then also, again, allows you to look for strictures. Maybe that patient has overflow incontinence or a mass right there at the anal canal. So in terms of high-resolution manometry, that's usually we proceed to that if endoscopy is otherwise unremarkable. And I personally think these images are beautiful. I think they're just as sexy as the ERCPs, but that's me. But just so that you guys know what you're looking at. So this is an image of a metametric tracing. This is the proximal sphincter. This is distal. And that probe, that manometry probe is sort of straddling the anal canal. And so this is the resting pressure, which usually is around 40 millimeters of mercury. When you ask the patient to squeeze right here, it goes up. It gets hotter. It's red. And you expect for them to be able to hold that for about 30 to 45 seconds. This image right here is a patient who has some injury, right? So here's your resting. They squeeze, but then it drops. They squeeze, and then it drops. And so oftentimes, that can be very helpful in assessing these patients. Also, we can look at sensation. We ask them to simulate defecation to see what happens to those muscles when they simulate defecation. But also, we can assess some reflexes. That can be important. So in terms of correlating the metametric tracings with endoscopy, that's where your endoanal ultrasound comes into play. And the two together can be very sensitive in terms of predicting what is happening with your patient and what to do for him or her. So this is a normal anatomy in which you have the ultrasound probe. The internal anal sphincter is usually hypoechoic. So this is your little line here. And then your external anal sphincter is sort of a mixed echogenic picture, kind of salt and peppery. And then in patients who have dysfunction or some sort of injury, you see that your external anal sphincter is disrupted here. You have this tear. You're not seeing that nice sort of heterogeneity that you see over here. And then this panel over here to the right, you see that there's disruption of the internal anal sphincter. And you don't see that nice hypoechoic band. And so this is actually an image of the patient that I started with in which this is the ultrasound here. Again, you see this defect. You see it's not that salt and peppery. Right here in the anterior, this is the anterior side, right, which is where we normally see these defects because of, again, the obstetric injury. And you probably have episiotomy here. And you're comparing it to the normal. And then I'm showing you the same manometric picture in which you have the normal resting pressure. You ask the patient to squeeze. It drops. So again, external anal sphincter weakness injury here correlating with your defect on the ultrasound. So it can be very effective. And so how do we manage patients with fecal incontinence today? Today, of course, we encourage general care, pads, caregiver support. If they're having overflow incontinence, we want to get them on a good bowel regimen. And most commonly, if all that, and then we say fiber as well if they're having some diarrhea. More often than not, we recommend biofeedback for these patients, which can be very effective depending on the motivation of the patient and then the expertise of your therapist. But then also there's these anal injection therapies that I want to talk to you about. So NASHA is this dextronomer that's in the stabilized hyaluronic acid. And it was approved back in 2012. It's a little bit difficult to get just because of insurance coverage, but it can be very helpful. And it's indicated for patients who have failed some of the medical therapy that I just told you about. And then based on your assessment of them, they have intact but a deficient anal sphincter. ♪♪♪

Colonoscopy

Endoscopy

High-resolution manometry

Endoanal ultrasound

Fecal incontinence