Introduction 1 5 1 6 2 7 8 4 8 9 3 10 6 8 11 12 9 13 13 14 15 17 In this study, the effectiveness of colonic irrigation for the treatment of persistent fecal incontinence and/or constipation after DGP was investigated. Materials and methods Patients with DGP and postoperative defecation disorders were selected for colonic irrigation between January 1999 and June 2003. The patients were offered colonic irrigation as additional or salvage therapy, as a colostomy was the final option for these patients. The inclusion criteria were invalidating fecal incontinence and/or constipation after DGP and a signed informed consent; exclusion criteria were patients not willing to perform the irrigation because of either embarrassment or wish for colostomy or patients physically and/or mentally not capable of performing irrigation. . The patient was considered satisfied when he or she indicated that the colonic irrigation rendered a major improvement of the quality of life. The improvement of quality of life was measured by a visual analog scale/specific questions within the questionnaire. The irrigation was performed in most patients as retrograde irrigation; only four patients performed antegrade irrigation through an appendico-cecostomy or a colostomy. Patients with fecal incontinence can gain continence as a result of colonic irrigation. This is called pseudo-continence because these patients are only continent, as there is no fecal filling of the rectum and distal colon. The definition of resolved constipation was no straining and no feeling of incomplete evacuation after defecation. Defecation occurred during irrigation in most of these patients. 1 2 Fig. 1 Biotrol® Irrimatic pump (Braun®)  Fig. 2 Irrigation bag (Braun®)  U P Results The questionnaire was sent to 74 patients. Fourteen patients did not wish to participate in the study for various reasons, and 14 patients did not return the questionnaire. Forty-six patients (62%) could be included for analysis of which 37 were female (80%), and these patients had an overall mean age of 59.3 ± 12.4 years. Complications of the DGP occurred in 23 (50%) patients of which 10 patients had two or more complications. Twenty-two patients suffered from constipation, 35 patients were still incontinent for feces, and seven patients had pain in the IPG pocket, leg, or anus. 1 Table 1 Medical history Medical history Number of patients (percentage of total) Anal rupture during delivery 13 (28%) Anal repair 14 (30%) Prolapse operation 19 (41%) Hysterectomy 17 (37%) Abdomino-perineal resection for rectum carcinoma 8 (17%) Sigmoid resection for sigmoiditis 2 (9%) Cholecystectomy 8 (17%) Anus atresia 1 (2%) Twenty-four (52%) patients used irrigation as an additional therapy for fecal incontinence in partially failing DGP. Eleven (24%) patients used irrigation for constipation and 11 (24%) patients for both. Most patients (91%) used the irrigation pump. Three patients added soap and one patient an enema to the water to achieve a better result. These were patients with constipation or a combination of fecal incontinence and constipation. Irrigation was usually performed in the morning (70%) and sometimes in the evening (16%). The frequency of irrigation was 0.90 ± 0.40 times per day. The amount of water used for irrigation was 2.27 ± 1.75 l with duration of 39 ± 23 min. Seventy-four percent of the patients with fecal incontinence irrigated in the morning, 17% in the evening, and 9% twice a day. For the patients with constipation, these numbers are, respectively, 45, 18, and 36%. Ninety percent of the patients with a combination of defecation disorders used the colonic irrigation in the morning. P P P 3 Fig. 3 Success of rectal irrigation for defecation disorders  Four patients, two with fecal incontinence, one with constipation, and one with both, performed antegrade irrigation through a (3) colostomy or an (1) appendico-cecostomy with good results, and all indicated that the irrigation improved their quality of life. 2 Table 2 Success of rectal irrigation in different etiologies for fecal incontinence before DGP Etiology Number of cases Success (%) during irrigation Congenital 1 1 (100%) Trauma 14 3 (21%) Pudendopathy 15 5 (33%) Spinal cord lesion 5 3 (60%) Abdomino-perineal resection for rectum carcinoma 8 3 (37%) Prolapse 2 0 (0%) Total 45 15 (33%) Side effects of the irrigation were reported in 61% of the patients: leakage of water after irrigation (43%), abdominal cramps (17%), and distended abdomen (17%). Twenty-four (53%) patients changed the irrigation method during their course to improve the results. Seven (16%) patients stopped the rectal irrigation: in five patients, the result was unsatisfactory; two other patients did not need the irrigation anymore because the complaints resolved completely. Finally, two patients received a permanent stoma. Discussion 18 19 20 13 18 16 21 23 24 26 16 17 23 27 15 17 14 28 32 1 5 1 5 Regarding the different underlying causes for fecal incontinence before DGP, the patients with a trauma to the anal sphincter have the lowest success rate and the patients with a spinal cord lesion have the highest success rate. It is not possible to draw conclusions about the statistical significance of these results because of the limited group size. 3 6 8 11 12 33 34 35 36 9 37 38 39 40 Conclusion Colonic irrigation is an effective alternative for the treatment of persistent fecal incontinence after DGP and/or recurrent or onset constipation additional to unsuccessful or (partially) successful DGP. Colonic irrigation is an undervalued and often forgotten treatment option, which deserves its rightful place among the other treatment modalities.