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Issue 2: The
Integration Crystal Ball (September 2001)
issue the article chosen to be discussed illustrates how can
a well designed study using traditional research methodology
lead to a multitude of data which can best be explained only
using the flow equation. The article will be discussed regarding
the data studied and the previously published articles used
as a database in their discussion.
Title: Clinical Manometric and EMG characteristics of Patients
Authors: A. Ferrara, J.H. Lujan J. Cebrian, S.W. Larach,
P.R. Williamson, M. Arroyo, J. Mills.
Journal: Tech Coloproctol (2001) 5:13-18
was done on 53 incontinent adult males Vs 72 age matched incontinent
adult females using clinical numerical scoring system which
relies on two main variables namely consistency of the leakage
material and the frequency of leakage modified by Pesctori et
al , a simplified life style score and anorectal physiologic
studies namely EMG and anorectal manometry.
They found that male patients had higher incontinence scores
at presentation and a longer history before presentation while
females tend to have a worse sphincter function than males where
mean maximum resting and squeeze pressures were significantly
lower in women and more women had sphincter asymmetry than men.
Both groups have the same EMG changes, PNTML delay and delayed
rectal sensation despite the disparity between the causes of
incontinence between both sexes.
the results illustrates the failure of the used clinical scoring
system to reflect the severity of the sphincter damage due to
the inclusion of frequency of incontinence episodes in the system.
According to the flow equation the frequency does not show itself
in the factors maintaining continence. In fact the frequency
may Vary over time e.g. a patient with incontinence to watery
stools will have the worst frequency score, if he develops watery
diarrhea and will have the best score if this diarrhea is treated
by simple medications which has no effect on the recto-anal
Since frequency and quality of life are important parameters
of success of any sort of treatment of anal incontinence from
the patients' point of view despite the lack of correlation
with the anorectal physiology, both should be included as two
separate adjunctive to the Clinico-functional scoring suggested
by the flow equation http://www.integratedcoloproctology.com/cal5.htm
Resulting in a composite scoring system CQF for anal incontinence
akin to the composite TNM staging for cancer.
Similarly the use of the un-integrated methodology ignores the
role of the rectum, sensations, reflexes, and recto-anal interaction
in inducing the worst types of incontinence in the presence
of an otherwise normal anal sphincter e.g. Overflow incontinence
due to fecal impaction.
(If you are interested in a detailed analysis of this article
and its brainstorming discussion from the flow equation point
of view we will be pleased to send the complete review on your