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Fecal incontinence is not a rare condition; it is an often unvoiced disorder. Approximately 2 % of the general population is affected, and it is more frequent with increased age. Various classifications are used to reflect the severity of symptoms and their impact on quality of life. Diagnostic management leading to therapeutic interventions depends on disease stage; in the majority of patients diagnostic techniques are simple and therapy is conservative, following a pragmatic approach. Diagnostics may help to distinguish functional from morphological causes and thus direct treatment. Operative therapy is indicated if conservative treatment fails to adequately relieve symptoms. Interventions range from minimally invasive outpatient procedures to more extended surgery with sphincter replacement. The mainstays of surgery for fecal incontinence are sphincter repair and sacral nerve stimulation. Although the indications for the various surgical procedures can overlap, there are distinct conceptual differences. In addition, practitioners are increasingly coming to appreciate that, for some patients, only a combination of various therapeutic modes will improve symptoms.

Although constipation is no longer treated primarily with surgery, surgeons continue to regularly see patients with constipation in ward and ambulatory settings. It is therefore critical to have a practical approach with respect to diagnosis, investigation, and management. Further, recent pharmacological and surgical advances are giving new hope to some patients with disabling chronic symptoms. This chapter gives an overview of constipation in general and then focuses on the more surgically relevant problem of chronic constipation. The chapter deliberately excludes a detailed discussion of defecation disorders (covered in Chap. 11), although this distinction is actually relevant only when specific surgery is considered.

Defecation disorders refers to the inability to efficiently and rapidly empty the rectum of its contents on demand. Functional and anatomic abnormalities coexist to give combined symptoms of 'obstructed defecation' a source of discomfort and impaired quality of life. These symptoms include abnormal anal function (anismus), perineal descent, rectocele and enterocele, rectal intussusception, and overt prolapse. Management is based on a detailed assessment of the terminal bowel anatomy and function to identify a cause. Medical treatment and pelvic floor retraining are first-line treatment. Various types of surgical approaches currently designed to correct anatomic abnormalities in order to improve function can be carried out in selected patients. In this difficult area of functional pelvic floor disorders, a multidisciplinary approach as developed in “pelvic floor clinics” is a useful adjunct to the traditional colorectal approach. Providing information to the patient and his/her relatives is essential, especially when surgery is considered.

The understanding of the pathophysiology of rectal prolapse syndromes has progressed. Untreated total prolapse leads to fecal incontinence. Obstructed defecation and incontinence have been linked to internal rectal prolapse. Proper functional assessment should lead to a treatment tailored to the patient and will include surgery in a subgroup of patients.

Perineal approaches to rectal prolapse are still indicated in old and frail patients. Laparoscopic rectopexy techniques have become the standard of care. Laparoscopic ventral mesh rectopexy minimizes the mobilization of the rectum and allows prolapses of the middle and posterior pelvic compartment to be corrected. Therefore the technique can be used to treat not only rectal prolapse but also complex rectoceles and enteroceles.

There is ongoing debate regarding the type of mesh to be used to minimize the risk for mesh-related problems and to avoid prolapse recurrence. Despite improved surgical technique, not all patients experience a functional recovery, and there is a permanent need to monitor the functional sequelae of prolapse surgery.

Irritable bowel syndrome (IBS) is characterized by chronic abdominal symptoms and irregular bowel movements without any cause that can be revealed by routine diagnostic assessment. While its pathophysiology has come to be better understood, new therapeutic approaches have been developed and are summarized in the new interdisciplinary S3 guideline to give concrete recommendations for symptom-based diagnosis and treatment. The Rome classification system characterizes IBS in terms of multiple physiological determinants contributing to a common set of symptoms rather than a single disease entity.

To achieve the best diagnostic results, a careful history and physical examination should be supplemented by basic laboratory testing, abdominal ultrasound, and, in women, gynecological examination.

Treatment options should be chosen according to the symptoms and might include dietary recommendations, psychological components, and symptomatic medication in addition to the general therapeutic principles. The prognosis differs by individual, depending on the patient’s optimism expectations and successful management.

Ulcerative colitis is a chronic, relapsing idiopathic inflammation of the rectum and variable lengths of the adjoining colon. Onset usually occurs during the third and fourth decades of life and commonly presents with bloody diarrhea. A diagnosis is made using a combination of endoscopic and histological evidence to distinguish it from other inflammatory colitides, in particular Crohn’s disease. The extent of the disease in terms of the amount of colon involved and the severity of the attacks both vary, and treatment is tailored depending on both these factors. Ulcerative colitis predisposes individuals to colorectal cancer, and surveillance is required for most sufferers. Acute severe colitis is the most serious manifestation of the disease and initially requires hospital treatment with intravenous steroids. Emergency surgery in the form of a subtotal colectomy and end ileostomy is vital in those not responding to medical treatment to avoid colonic perforation. There are two major elective procedures: restorative proctocolectomy (ileoanal pouch procedure) and panproctocolectomy. Laparoscopic surgery is now an option for both emergency and elective procedures.

The exact etiology of Crohn’s disease remains unclear, but current evidence suggests that the intestinal mucosal barrier is compromised, allowing invasion of intestinal bacteria into the bowel. Conservative measures are the mainstay of treatment. Surgery is primarily used to treat complications of Crohn’s disease and to improve quality of life. Certain situations such as enterovesical fistulas are absolute indications for surgery. In isolated ileocecal Crohn’s disease, primary ileocecal resection is a therapeutic alternative equivalent to the escalation of medical treatment. Adequate preoperative preparation, including improving nutritional status, weaning off or stopping immunosuppressive medication, and preoperatively draining abscesses, can decrease complication rates of surgery for Crohn’s disease. Unless neoplasia is present, bowel-sparing techniques (strictureplasty, limited resections) should be used. The laparoscopic approach is possible for most indications; its superiority over the open approach has been shown for primary ileocecal resection. Seton drainage is a good option to retain quality of life for patients with complex perianal fistulas.

Indeterminate colitis is an exclusion diagnosis that is used for 10–15 % of patients who have had a colectomy for inflammatory bowel disease (IBD)–related colitis when there are no definite features of ulcerative colitis or Crohn’s colitis. The term is reserved for operated patients; those still not operated on and in whom the diagnosis is an uncertain are now considered to be 'IBD unclassified'. The specific diagnosis given to a patient with IBD colitis depends on the clinical course and features, the endoscopic appearance, and to a large extent the microscopic findings, though it is evident that there is room for judgment and uncertainty. Over time, many patients with an indeterminate colitis will be reconsidered and labeled with a definite diagnosis, often ulcerative colitis. With the advent of restorative proctocolectomy including a pelvic pouch, this diagnostic dilemma has become more important. Most surgeons will not recommend a pelvic pouch to a patient with a definite diagnosis of Crohn’s disease, since most studies report a higher risk of pelvic septic complications and pouch failure in these patients. However, most agree that the risk in a patient with an indeterminate colitis is considerably less, with an only a slightly increased complication rate, compared with those with an ulcerative colitis.

Colonic diverticulosis is among the most common diseases in developed Western countries, and its incidence is increasing as the average age of the population increases. Its etiology remains largely unknown. It is assumed that intestinal innervation disorders and structural alterations of the musculature induce abnormal contractile patterns with increased intraluminal pressure, thereby promoting the development of diverticula. The location of diverticula within the colon varies significantly among different regions of the world. In Western countries, primarily left-sided diverticulosis, particularly involving the sigmoid colon, has been well-described. This is in contrast to findings in Asia, where right-sided diverticulosis dominates. The actual prevalence of diverticulosis is difficult to determine because most individuals are asymptomatic. Acquired diverticular disease of the colon has been estimated to occur in 30 % of the population over the age of 45 years; 10–25 % of these individuals develop symptomatic diverticulitis. The clinical spectrum of diverticular disease varies from asymptomatic diverticulosis to symptomatic disease with potentially fatal complications, such as perforation or bleeding. Acute diverticulitis is treated according to severity. Computed tomography permits the complete evaluation of the location and extent of the inflammatory process, allowing appropriate, adapted clinical management. Treatment recommendations depend on the disease stage and include conservative approaches with observation and dietary modifications, as well as antibiotic treatment, abscess drainage, and surgery. A prerequisite for therapeutic decision making is an exact, comprehensive, and applicable classification of the disease before treatment. Several systems for classifying diverticular disease have been presented, but none of them has yet been universally adopted.

Colitis other than ulcerative colitis or Crohn’s disease affects a large group of patients. Etiology is multifactorial and includes infection, hyperosmolar formula feeding, a lack of breast milk, ischemia and reperfusion injury, Clostridium difficile, and viral and parasitic agents. The main symptoms are diarrhea; leukocytosis; fever; abdominal pain or cramping; bloody, mucoid, green, foul-smelling stools; the urge to defecate; and others such as dehydration, electrolyte disturbances, nausea, vomiting, malaise, anorexia, hypoalbuminemia, and anasarca. Diagnostic procedures include laboratory studies, endoscopy, plain abdominal radiography, computed tomography, and histology. Therapy depends of the exact diagnosis and may include conservative treatment; antibiotics causing the condition should be stopped and the patient should be rehydrated and given metronidazole/vancomycin). Surgery is required in rare cases to treat infections that worsen or do not respond to conservative treatment, or when there are any complications. Various approaches can be used, including early subtotal colectomy, colectomy, colostomy, ileostomy, and resection of the diseased bowel.