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Leafs Nation Podcast: Old Players, Old Identities, New CBA
Leafs Nation Podcast
July 16 2012 11:41PM
This week, Danny Gray and I discuss three main topics: the Winter Classic Alumni Game (and the roster that was recently announced), this post by Michael Langlois at Vintage Leaf Memories, and, of course, the recent CBA negotiations between the NHL and the NHLPA.
Happy listening.
Report: Leafs make pitch for Jonathan Bernier
Cam Charron
July 16 2012 08:23PM
Hearing the Leafs have put in an offer to G Jonathan Bernier.
— Andi Petrillo (@andipHNIC) July 17, 2012
Via CBC's Andi Petrillo.
It isn't much to go on, but it appears as if Brian Burke thinks the price may be right for the Leafs to acquire Los Angeles Kings' backup and former first-round draft pick Jonathan Bernier.
Bernier, of course, has played just 48 NHL games in his career, posting a save percentage of .910 and an even strength save percentage of .913. The NHL average over that span is .921.
Ben Scrivens vs. the NHL
Cam Charron
July 16 2012 10:54AM
So our fact-finder Rob Pettapiece over at NHL Numbers has written a post about AHL goaltenders. Using a tested and true baseball method of looking at how these goalies did against NHL competition, we can come up with a much better metric than simply "save percentage" for evaluating how they played.
Of course, like most goaltenders, there's still little predictive value, but in the case of Ben Scrivens, say, is there a better goalie than we initially thought? Do we have a goaltender who fared better against NHL competition with the Marlies than he did against AHL competition?
In June, I wrote that Scrivens had the fourth best save percentage among AHL goaltenders who faced more than 1500 shots over the last two seasons.
The NHL's initial proposal
Cam Charron
July 16 2012 06:18AM
The only thing we have to fear is Fehr himself
There's already some absurdist alarmist sentiment when dealing with the NHL's initial proposal to the NHLPA, details of which were leaked Friday night.
The good news for hockey fans is that, unlike the lockout of 2004-05, the NHL's one major demand, a salary cap, was considered a non-starter for the PA. The season was missed, the PA suffered some leadership changes, and they reluctantly agreed to a deal that was a clear winner for the league at the time.
Fast-forward seven years, and the real big issue is how to split a $3 billion pie.
Nation Radio - July 14, 2012
July 15 2012 11:22AM
While the UFA "frenzy" remains a sort of tepid, apathetic singles dance, in the distance one can hear the rumble of thunder that signifies the impending battle between the league and the NHLPA. Gary Bettman has already fired a few shots over the bow of Donald Fehr and company, so it looks like the CBA talks are going to be...contentious at the very least.
For now, we'll continue to ignore the whole "there might be another lock-out" thing and keep on talking trades and stats. This week, Allan invited number crunchers and hockey writers from around the league including Benjamin Wendorf, James Mirtle and Corey Pronman to help with our denial.
This is Nation Radio.


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123 October 29, 2012
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Some nice oral
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The statistic - great news for Wikipedians, terrifying for the rest of us - was reported in the communications regulator's annual report on children's "media literacy", out today.
Only a slightly larger proportion - 37 per cent - believe results are ranked on their usefulness or relevance. The next generation of cynics - 14 per cent of 12 to 15-year-olds - said websites pay money for the top spots.
As reported at The Register... [theregister.co.uk...]
[edited by: tedster at 11:21 pm (utc) on Oct. 6, 2009] [edit reason] fix formatting problem [/edit]
Can you imagine the argument between 'the student who is convinced' and the teacher? But, that's not right, Google says...
so we left ..decades ago ..


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A newer version of AirSnare is available.
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Updated: 03/05/2014 12:22 PM
Created: 03/05/2014 12:13 PM WHEC.com
The Ontario County man accused of causing a standoff that shut down a Victor neighborhood pleaded guilty in court Wednesday morning.
Ryan Whidden pleaded guilty to second-degree criminal possession of a weapon. He was sentenced to 10 years in prison. The sentence includes five years of post-release supervision.
Police say Whidden fired at parked cars outside his Ketchum Street house last March in Victor. He then barricaded himself in home and held his wife against her will. Officers say they forced Whidden to surrender after the 12 hour standoff by using tear gas.
News10NBC/WHEC-TV welcomes your opinion and interaction on our website, but please remember to keep it clean. If you're advertising for another business, being profane, vulgar or slanderous your post will be deleted. By commenting on this website, you agree that anything you post may be used, along with your name and profile picture, in accordance with our Privacy Policy and the license you have granted pursuant to our Terms of Use. Comments are not pre-screened before they posted.


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Spotlight Article:
Energy-Saving Strategies - Think Again
The rules regarding home energy savings are changing. New technologies and shifting realities are showing us that many of the old energy-saving dictums are now obsolete. If, for instance, you look at the top energy-saving ...
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Water Heaters Get an Efficiency Makeover Courtesy of DOE
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NIALL, HAPPY 19TH!my best whishes goes to niall, who turns 19.i hope he has a good one.oh, and niall, had some "birthday sex" yet?
1D STORE IN NYC!!!yup, it opened last week in NYC near mad. square garden!!!HAHAH IM GOING, TO ALL YA SUCKAHS WHO DONT LIVE NEAR THERE!!IM EVVILL >:{Dhttp://www.youtube.com/watch?v=Xqikg5JAUHw
1D AT THE TODAY SHOW!!tHERE COMING AT THE 13th AND the 14th!!!F*CKING SCHOOL!http://www.youtube.com/watch?v=8SL5HmgQ5kg
Imagine: Niall James Horan (for Animecrazynet)Imagine: Niall Horan- Will You Marry Me? It has been two years since me and Niall got together. I sometimes wonder, how in the world did I end up with someone so cheeky, so beautiful as Niall, let alone being a celebrity and all. These past two years with him have been so....magical! I remember waking up on a normal Monday morning and all I see is a face: a peachy face with heavenly blue eyes and blonde hair. It could've been none other than my sweet little Nialler."Good morning babe," he said with his cute Irish accent."Good morning Niall", you start to say. "What are you doing here in my house at 6 AM?""Well, what other reason than to come to your house than to celebrate your birthday! I have the whole day planned. And the day starts at breakfast time..."Oh crap I forgot my own birthday! Even my own boyfriend remembers, BUT NOT EVEN ME!! I kinda felt sorry for Niall going through all that trouble, just for me! How sweeter can he get? Just like he
Liam got a new tattt...http://www.sugarscape.com/main-topics/lads/778317/liam-payne-shows-new-arm-tattoo-quotesee it for your self!
IMPORTANTTT!!!!!!~!1D is comin back to The Alan Carr interviews! The episode is set to be on FRIDAY!!DONT MISS IT!!
NIALL IS SINGLE!!!HE IS SINGLE!!! YAYSEE HERE!http://www.mrpaparazzi.com/post/20980/Good-news-Niall-Horan-is-single-and-ready-to-mingle-
LOUIS AND LIAM HAVE TATTOOS!I HAVE PROOF HERE:http://www.thesun.co.uk/sol/homepage/showbiz/4594832/One-Direction-star-Harry-Styles-reveals-new-arm-tattoos.html
MY POOR BABY!OH MY GOD! MY POOR BABY!!!http://sphotos-b.ak.fbcdn.net/hphotos-ak-ash3/c11.0.403.403/p403x403/560838_492256044133011_1896314392_n.jpgWHAT HAPPENED?!?!?!?
LITTLE THINGS.http://www.listenonrepeat.com/watch/?v=6wBzR7zhA0g&featurelcpIT'S FUCKING PERFECTION AND LKJNVGLRSVNAVJUNRAVLAR.I WON'T LET THESE LITTLE THINGS SLIP OUT OF MY MOUTH.AND ALL YOUR LITTLE THINGS.I WILL BE SINGING THIS ALL SAY UNTIL THE END OF MY LIFE.
rock meHOLY CRAP 'ROCK ME' GOT LEAKED FROM THE 'TAKE ME HOME' ALBUM AND IT'S FREAKING AWESOME! HARRY STARTS THE SONG! JUST GAAAH I WAS SQUEALING SO MUCH MY DAD HAD TO TELL ME TO BE QUIET...OOPS... YOU MUST LISTEN!http://www.youtube.com/watch?v=-cgmiZWZRSEhttp://a.tumblr.com/tumblr_mcvy2dxBTb1rpk5fio1.mp3Amazballs right!!!
...I need new friends...oh gosh... look what my friend emailed me:http://www.youtube.com/watch?v=YHWC0ha_g00
Wowhttp://www.youtube.com/watch?v=yslrb52Di5w&feature=relatedAll I can do is be mesmerized by his hands. (don't take that pervertedly!)http://www.youtube.com/watch?v=rJm0fdyjbncI'm amazed... truly amazed...
The Return of 1DDH {HELP ME}Hey there lovelies!!!Guess what!! After about a month of writer's block, I should be starting to continue my stories very very soon! Guess what again!! I only have one week of classes left, then one week of exams, then five days of orientation and then SCHOOL IS OUT!!!!!!! Woohoo!!!!!! I'm very excited, also, it's only 55/56 days until I leave for Italy!!!!Anyway, back to the original point of this journal. I am in the process of writing the next chapter for 1DDH, the 1D Directioner House, and I need the help of those involved. This is the chapter where we kidnap, or should I say, catnap (Lol, no I shouldn't xDD), One Direction! But not everyone can come to actually kidnap them, so I am going to use a random number generator to decide who comes. That way it is fair.The problem is, I don't know how many people you need to kidnap five people? How many people do you guys think should go on the 'capture hunt'? I need to know and decide ASAP.Thanks again!~Summer xoxo
PerfectionThe most perfect song EVER live! Oh my gosh... just... this is just so perfecthttp://www.youtube.com/watch?v=yUjSdV8IhoI
I'M ALREADY IN LOVE WITH LWWYOMG LIVE WHILE WE'RE YOUNG BY THE AWESOME ONE DIRECTION CAME OUT TODAY...I guess you could say that..anyway...HERE'S ANOTHER PLZ ACCOUNT I MADE FROM THE VIDEOOOOMG I LOVE HIS FACIAL EXPRESSIONS :iconzaynejplz:HERE YA GO: :iconzaynlwwyplz:How to Use:: iconzaynlwwyplz: (But don't use the space between the ":" and the "i")DONT YOU LOVE IT????? I DOOOOO!!!!!!!!!!!!!! I WISH I COULD MAKE FACIAL EXPRESSIONS LIKE THAT. SPREAD THE WORD :iconzaynejplz:
LIVE WHILE WE'RE YOUNGHOLY FUDGE CAKES! THE OFFICIAL VIDEO FOR LIVE WHILE WE'RE YOUNG BY ONE DIRECTION IS ON YOUTUBE! I KEEP WATCHING IT ON REPLAY! THE SONG IS AMAZING, ALL OF THE BOYS HAVE SOLOS, THERE'S HOT GUYS IN WET T-SHIRTS, ZAYN MAKES SOME PRETTY ROCKING FACES LIKE THIS :iconzaynlwwyplz: AND I JUST LOVE IT! THEY'RE ALL SO AMAZING! I'M SPAZZING SO MUCH AND DANCING LIKE AN IDIOT!!! I'M SMILING LIKE CRAZY! YOU HAVE TO WATCH! LIVE WHILE WE'RE YOUNG FOREVER!!!!http://www.youtube.com/watch?v=AbPED9bisSc
Things just keep getting better....HAH. SARCASM.So tonight was the opening night of my school production, 'Little Shop of Horrors.'I'd like to say that everything went brilliantly........but.....It didn't.My good lad, Justin who is a senior is working the sound (which is not easy at all) has been like, the only thing keeping me sane. I'm really glad that I got to know him. He makes me laugh and he's a lot of fun to be around. Plus he's cute (;I'll get into that more later.Back to tonight.....My cue's got out of order on me the last minute. Almost as if something touched them and messed them up. So....some of the lights....didn't....work.......but not everyone noticed. So it was no big deal but still, I felt like complete rubbish. And I still do.And then poor Justin......within five minutes, a girl's microphone started making weird noises. Like this; SHSHSHSHSHSHHHHHHSHSHSHSHSHSHHHHHHHSHSHSHHSHHHHHHHH.....FJKASJFKLSJFLKASJFKSA.....SHSHSHSHHHHHHHSHSHSHSHHSHHHHH...................................................FKJASLJVLASKFHKAS
1D sings the wrong lyrics...http://www.youtube.com/watch?v=lO1f5BPGrnQI CHOCKE ONMY POP TART, thats how funny it is!!!


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New $118m Prison Headquarters to be completed in 2014
Published on Dec 10, 2012 8:06 PM
Work has begun inside the Changi Prison compound for a new $118.5 million Prison Headquarters.
There will be four buildings and several smaller ancillary buildings that will house office facilities, a multi-purpose hall, a club house and an auditorium. These will all be built on vacant land next to the prison complex and be completed in 2014.
The project was announced yesterday by Singapore-based Sembawang Engineers and Constructors (SEC), which is owned by the Punj Lloyd Group, an Indian conglomerate.
While the construction group has previously completed institutional projects such as schools and hospitals, this is the first time it is working on a prisons project.
To continue reading, log in if you are a subscriber
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Orb is the obvious choice, and I'm confident he has a better chance at getting the distance in the derby. The distance factor was present in the Florida Derby. Yes, Itsmyluckyday won at a mile and 1/16 in the Holy Bull, but when he added a sixteenth to 1 mile and 1/8, he couldn't last. I have a feeling that he will have an issue with the full ten furlongs in the derby. Orb on the other hand has been winning impressively in each start with added distance. Shug will have him more than ready for the big race.
Connect With
"The Dark Horse"
Here are some of my racing photo albums!
And here are all of the tracks I have visited in person!
Join 39,279
other passionate horse racing fans!


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This employer has taken extra steps to respond to reviews and provide job seekers with accurate company information, photos, and reviews. Interested for your company?Learn More.
Interview Question
Interview Answer
1 Answer
Gosh. I asked myself whether this was a test of strategic thinking, blind devotion, or whether you can tell your boss what they want to hear. I ended up taking the high road, and said that I didn't have enough information to make that call.
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We want to ensure that making a return is as easy and hassle-free as possible! If for any reason you decide that your purchase just isn't for you, simply return the item within 30 days of receipt and we'll cover the return shipping when you choose our FREE Pre-Paid Return Shipping Label. Learn more about our return policy.
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Mark Wills to Headline Yakima's 4th of July Celebration
Selah Kidnap Suspect In Jail
Hit-and-Run Driver Turns Self In
Put Another 2 cents in Your Pocket-Gas Prices Fallen in Yakima
National and State Recognition for Memorial's Diabetes Education
Yakima Valley Memorial Hospital is proud to announce the expansion of its diabetes education programs. The Washington State Attorney General's office awarded Memorial a grant in the amount of $202,800. The money comes from a consumer protection settlement with GlaxoSmithKline pharmaceuticals.


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February 26, 2015
(Dublin, Ireland) The orangutan appears to give the kiss of life to a floundering duckling (well moorhen chick) abandoned by its mother.
The animal care team at Dublin Zoo reviewed the youtube clip and can confirm that the orangutan saving the little moorhen chick is in fact a male Bornean orangutan named Jorong who lived in Dublin Zoo for twelve years until he moved to Dudley Zoo in 2008 as part of an international breeding program.
Jorong was born in 1995 in Chester Zoo and came to Dublin Zoo in 1996. He had a lovely nature, was always a little inquisitive and very gentle which you can tell from the clip. During his time in Dublin he fathered a female orangutan named Mujur, who still lives in Dublin Zoo with the zoo's group of Bornean orangutans.
Click Here to access the online Public Inspection File
Viewers with disabilities can get assistance accessing this station's FCC Public Inspection File by contacting the station with the information listed below. Questions or concerns relating to the accessibility of the FCC's online public file system should be directed to the FCC at 888-225-5322, 888-835-5322 (TTY), or firstname.lastname@example.com.


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WASHINGTON — Giant Food has removed brands of chili seasoning kits from store shelves because they may contain peanut and almond allergens that are not declared on the products' ingredient statements. These products are safe…
Don\'t depend too much on \"hypoallergenic\" labels at the
store. A new study finds they might not be accurate.
When most people go to a hospital, a clinic, or even a new
doctor, they are asked about any allergies to medications. Ten percent say they
are allergic to penicillin. But it turns out that they may have
outgrown that allergy years ago.
Nutritionists may encourage limited amounts of salt, but some allergy sufferers can\'t get enough of it at a local salt cave.
The start of a new school year can be a challenging time for any
child. But it has the potential to be exceptionally tough for students with
severe food allergies.
It\'s the time of year when allergy season is making many people miserable — and one of the culprits may be a parasite lurking in your home.
This week is a tough one for those with allergies. Allergists say the
most recent pollen count in our area sky high and the rain may not be helping.
Matthew Fischer has had asthma all his life, but it wasn't until helping a friend who was diagnosed with the respiratory disease in her 50s that the career entrepreneur had the idea to help asthmatics everywhere.
The pollen count was above 1,000 last weekend. A count of 75 is considered high.
It\'s the time of year when people begin the battle against spring
allergies — and the D.C. area is particularly vulnerable, according to a local
Find out which Virginia city makes the top 10 list of worst places to live for people with allergies.
You hear it all the time – people say they never suffered from allergies until they came here. But truth be known, there are no allergy-free zones.
It\'s still winter. But while the trees are bare, allergy sufferers are starting to sneeze their way toward spring.
Many have had to endure repeated allergy shots, particularly for hay fever. But those injections could be replaced by a simple pill or a drop placed under the tongue.
Food allergies in children have risen 50 percent since the late 1990s, with Maryland and D.C. having some of the highest rates in the country. And no one knows why.


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The latest Vector from OCZ uses the Indilinx Barefoot 3 controller paired with OCZ's own branded NAND and the firmware. This marked the first drive from OCZ with all in-house construction. How does the drive fare against other SSDs on the market? We take the 256GB version out for a spin. Let's find out. No related posts. Read More »
OCZ Agility 4 256GB SSD
SSD's are growing ever more popular, and we've reviewed a lot of them by now. Today we're checking out the 256GB version of OCZ's newest addition to the SSD lineup: the OCZ Agility 4. No related posts. Read More »
Kingston Wi-Drive 64GB
Earlier this year, we released a review of the Kingston Wi-Drive. Since then, Kingston has made a few changes to the Wi-Drive, including adding support for a wireless browser, and even greater capability. Check out exactly how well the new Wi-Drive performs! No related posts. Read More »
Kingston Wi-Drive 16 GB & Seagate GoFlex Satellite 500 GB
The mobile device market is booming, and more and more users want a bit more space to store movies and video for their tablets or smartphones. These two devices should do the job well! No related posts. Read More »
Kingston latest gadgets at CES 2012
Kingston shows off their latest red Hyper Limited Edition memory modules, next concept T1 modules, a 64GB system running a high demanding composition, and latest Ultrabook Flash Drives. No related posts. Read More »
Kingston DataTraveler HyperX 3.0 64GB
The Kingston DataTraveler HyperX 3.0 is supposed to be Kingston's fastest flash drive to date. We'll compare it with a USB 3.0 flash drive they released a few months ago to see if it's true. No related posts. Read More »


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Colorblocking fans, get ready to do your happy dance, 'cause I'm found an idea I know you're going to be into.
read more
We can't get enough of fun, printed denim this spring, but if you're wondering "what's the next big jeans thing?" we've got your answer--patchwork and colorblock jeans. Designers like J Brand, Rag & Bone and Current/Elliott are all ... Read Post
Colorblocking - although not a real word - seems to be on everyone's mind this spring. We introduced the funky, bold colorblock dresses (perfect for work and play) and then the retro chic colorblock heels that actually go with every... Read Post


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Madonna certainly knows what songs she'll be performing at halftime during this Sunday's Super Bowl, and now, thanks to NFL Magazine, we all have a hint.
It appears her set list will include her new single, "Gimmie All Your Luvin," along with classics, "Ray of Light" and "Vogue."
A CBSSports.com report cites a blurb in the new NFL Magazine as stating, "Though Madonna's set list was not officially announced at press time, fans might expect her to give all her luvin', provide a ray of light and be in vogue with her music. The Super Bowl is almost a national holiday, after all."
The New York Post also reports Madge's 12-minute set will include "Gimmie All Your Luvin," "Ray of Light" and "Vogue," along with "Music" and "Holiday."


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Motorcycle run to honor murdered teen
Las Cruces, NM (KTSM) — Dozens of motorcycle riders will hit the highway this weekend to remember a local teen who died far too young. Jennifer Crecente passed away in 2006 when she was just 18 years old. She didn't die from a childhood disease, she wasn't killed in a car wreck, she was murdered by her boyfriend.
A motorcycle run on Sunday is aimed at raising money to help fund teen dating awareness efforts, so that deaths like Jennifer's can be prevented.
"Losing my granddaughter was the worst thing i've ever experienced in my life and i don't want anyone to have to go through this. My son was actually the one that started researching this, even though i'm a psychologist, and he really found out how prevalent this was," said Dr. Elizabeth Richardson, Jennifer's grandmother.
Studies show 44 percent of women will be in a an abusive relationship by the time they graduate college. The first annual Jennifer Ann's motorcycle run will start at Barnett Harley Davidson at 10 a.m. on Sunday. It costs $10.


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DaNieLa RoCkZ
Apr 26th, 2005, 11:41 AM
Daniela was down 0-3 in second and came back to have a Mp at 5-4 but wasted it but was able to close it out!! Good job.. you need to play better against Bovina though!
View Full Version : Daniela Hantuchova def. Karolina Kosinska 6-4 7-5!


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From Wikipedia, the free encyclopedia - View original article
Diagram showing normal anatomy of anal canal and rectum. | |
DiseasesDB | 6763 |
MedlinePlus | 003135 |
eMedicine | article/268674 |
MeSH | D005242 |
Diagram showing normal anatomy of anal canal and rectum. | |
DiseasesDB | 6763 |
MedlinePlus | 003135 |
eMedicine | article/268674 |
MeSH | D005242 |
Fecal incontinence (FI), also called faecal incontinence, bowel incontinence, anal incontinence, or accidental bowel leakage, is a lack of control over defecation, leading to involuntary loss of bowel contents—including flatus (gas), liquid stool elements and mucus, or solid feces. FI is a sign or a symptom, not a diagnosis. Incontinence can result from different causes and might occur with either constipation or diarrhea. Continence is maintained by several inter-related factors, and usually there is more than one deficiency of these mechanisms for incontinence to develop. The most common causes are thought to be immediate or delayed damage from childbirth, complications from prior anorectal surgery (especially involving the anal sphincters or hemorrhoidal vascular cushions) and altered bowel habits (e.g. caused by irritable bowel syndrome, Crohn's disease, ulcerative colitis, food intolerance, or constipation with overflow incontinence).[1] An estimated 2.2% of community dwelling adults are affected.[2]
Fecal incontinence has three main consequences: local reactions of the perianal skin and urinary tract, including maceration (softening and whitening of skin due to continuous moisture), urinary tract infections, or decubitus ulcers (pressure sores);[1] a financial expense for individuals (due to cost of medication and incontinence products, and loss of productivity), employers (days off), and medical insurers and society generally (health care costs, unemployment); and an associated decrease in quality of life.[3] There is often reduced self-esteem, shame, humiliation, depression, a need to organize life around easy access to bathroom and avoidance of enjoyable activities. FI is an example of a stigmatized medical condition, which creates barriers to successful management. People may be too embarrassed to seek medical help, and attempt to self-manage the symptom in secrecy from others.
FI is one of the most psychologically and socially debilitating conditions in an otherwise healthy individual, but it is generally treatable.[2] Management may be achieved through an individualized mix of dietary, pharmacologic and surgical measures. Health care professionals are often poorly informed about treatment options,[2] and may fail to recognize the impact of FI.[3]
There is no globally accepted definition,[1] but fecal incontinence is generally defined as the recurrent inability to voluntarily control the passage of bowel contents through the anal canal and expel it at a socially acceptable location and time, occurring in individuals over the age of four.[1][2][3][4][5] "Social continence" has been given various precise definitions for the purposes of research, however generally it refers to symptoms being controlled to an extent that is acceptable to the individual in question, with no significant impact on their life. There is no consensus about the best way to classify FI,[5] and several methods are used.
Symptoms can be directly or indirectly related to the loss of bowel control. The direct (primary) symptom is a lack of control over bowel contents which tends to worsen without treatment. Indirect (secondary) symptoms, which are the result of leakage, include pruritus ani (an intense itching sensation from the anus), perianal dermatitis (irritation and inflammation of the skin around the anus), and urinary tract infections.[1] Due to embarrassment, people may only mention secondary symptoms rather than acknowledge incontinence. Any major underlying cause will produce additional signs and symptoms, such as protrusion of mucosa in external rectal prolapse. Symptoms of fecal leakage (FL) are similar, and may occur after defecation. There may be loss of small amounts of brown fluid and staining of the underwear.[2]
FI can be divided into those people who experience a defecation urge before leakage (urge incontinence), and those who experience no sensation before leakage (passive incontinence or soiling).[5] Urge incontinence is characterized by a sudden need to defecate, with little time to reach a toilet. Urge and passive FI may be associated with weakness of the external anal sphincter (EAS) and internal anal sphincter (IAS) respectively. Urgency may also be associated with reduced rectal volume, reduced ability of the rectal walls to distend and accommodate stool, and increased rectal sensitivity.[3]
There is a continuous spectrum of different clinical presentations from incontinence of flatus (gas), through incontinence of mucus or liquid stool, to solids. The term anal incontinence often is used to describe flatus incontinence,[5] however it is also used as a synonym for FI generally. It may occur together with incontinence of liquids or solids, or it may present in isolation. Flatus incontinence may be the first sign of FI.[2] Once continence to flatus is lost, it is rarely restored.[5] Anal incontinence may be equally disabling as the other types.[6] Fecal leakage, fecal soiling and fecal seepage are minor degrees of FI, and describe incontinence of liquid stool, mucus, or very small amounts of solid stool. They cover a spectrum of increasing symptom severity (staining, soilage, seepage and accidents).[1] Rarely, minor FI in adults may be described as encopresis. Fecal leakage is a related topic to rectal discharge, but this term does not necessarily imply any degree of incontinence. Discharge generally refers to conditions where there is pus or increased mucus production, or anatomical lesions that prevent the anal canal from closing fully, whereas fecal leakage generally concerns disorders of IAS function and functional evacuation disorders which cause a solid fecal mass to be retained in the rectum. Solid stool incontinence may be called complete (or major) incontinence, and anything less as partial (or minor) incontinence (i.e. incontinence of flatus (gas), liquid stool and/or mucus).[2]
In children over the age of four who have been toilet trained, a similar condition is generally termed encopresis (or soiling), which refers to the voluntary or involuntary loss of (usually soft or semi-liquid) stool.[7] The term pseudoincontinence is used when there is FI in children who have anatomical defects (e.g. enlarged sigmoid colon or anal stenosis).[2] Encopresis is a term that is usually applied when there are no such anatomical defects present. The ICD-10 classifies nonorganic encopresis under "behavioural and emotional disorders with onset usually occurring in childhood and adolescence" and organic causes of encopresis along with FI.[8] FI can also be classified according to gender, since the cause in females may be different from males, for example it may develop following radical prostatectomy in males,[9] whereas females may develop FI as an immediate or delayed consequence of damage whilst giving birth. Pelvic anatomy is also different according to gender, with a wider pelvic outlet in females.
Several severity scales exist. The Cleveland Clinic (Wexner) fecal incontinence score takes into account five parameters that are scored on a scale from zero (absent) to four (daily) frequency of incontinence to gas, liquid, solid, of need to wear pad, and of lifestyle changes.[1] The Park's incontinence score uses four categories:
The fecal incontinence severity index is based on four types of leakage (gas, mucus, liquid stool, solid stool) and five frequencies (once to three times per month, once per week, twice per week, once per day, twice or more per day). Other severity scales include: AMS, Pescatori, Williams score, Kirwan, Miller score, Saint Mark's score and the Vaizey scale.[2]
FI may present with signs similar to rectal discharge (e.g. fistulae, proctitis or rectal prolapse), pseudoincontinence, encopresis (with no organic cause) and irritable bowel syndrome.[2]
The mechanisms and factors contributing to normal continence are multiple and inter-related. The puborectalis sling, forming the anorectal angle (see diagram), is responsible for gross continence of solid stool.[3] The IAS is an involuntary muscle, contributing about 55% of the resting anal pressure. Together with the hemorrhoidal vascular cushions, the IAS maintains continence of flatus and liquid during rest. The EAS is a voluntary muscle, doubling the pressure in the anal canal during contraction, which is possible for a short time. The rectoanal inhibitory reflex (RAIR) is an involuntary IAS relaxation in response to rectal distension, allowing some rectal contents to descend into the anal canal where it is brought into contact with specialized sensory mucosa to detect consistency. The rectoanal excitatory reflex (RAER) is an initial, semi-voluntary contraction of the EAS and puborectalis which returns prevents incontinence following the RAIR. Other factors include the specialized anti-peristaltic function of the last part of the sigmoid colon, which keeps the rectum empty most of the time, sensation in the lining of the rectum and the anal canal to detect when there is stool present, its consistency and quantity, and the presence of normal rectoanal reflexes and defecation cycle which completely evacuates stool from the rectum and anal canal. Problems affecting any of these mechanisms and factors may be involved in the cause.[2]
FI is a sign or a symptom, not a diagnosis,[5] and represents an extensive list of causes. Usually, it is the result of a complex interplay of several coexisting factors, many of which may be simple to correct.[5] Up to 80% of people may have more than one abnormality that is contributing.[11] Deficits of individual functional components of the continence mechanism can be partially compensated for a certain period of time, until the compensating components themselves fail. For example, obstetric injury may precede onset by decades, but postmenopausal changes in the tissue strength reduce in turn the competence of the compensatory mechanisms.[1][4] The most common factors in the development are thought to be obstetric injury and after effects of anorectal surgery, especially those involving the anal sphincters and hemorrhoidal vascular cushions.[1] The majority of incontinent persons over the age of 18 fall into one of several groups. These are: those with structural anorectal abnormalities (sphincter trauma, sphincter degeneration, perianal fistula, rectal prolapse), neurological disorders (multiple sclerosis, spinal cord injury, spina bifida, stroke, etc.), constipation/fecal loading (presence of a large amount of feces in the rectum with stool of any consistency), cognitive and/or behavioral dysfunction (dementia, learning disabilies), diarrhea, inflammatory bowel diseases (e.g. ulcerative colitis, Crohn's disease), irritable bowel syndrome, disability related (people who are frail, acutely unwell, or have chronic/acute disabilities), and those cases which are idiopathic (of unknown cause).[5][12] Diabetes mellitus is also known to be a cause, but the mechanism of this relationship is not well understood.[13]
Anorectal anaomalies and spinal cord defects may be a cause in children. These are usually picked up and operated upon during early life, but continence is often imperfect thereafter.[2]
The functioning of the anal canal can be damaged, traumatically or atraumatically. The resting tone of the anal canal is not the only factor which is important, both the length of the high pressure zone and its radial translation of force are required for continence. This means that even with normal anal canal pressure, focal defects such as the keyhole deformity can be the cause of substantial symptoms. EAS dysfunction is associated with impaired voluntary control, whereas IAS dysfunction is associated with impaired fine tuning of fecal control.[1] Lesions which mechanically interfere with, or prevent the complete closure of the anal canal can cause a liquid stool or mucous rectal discharge. Such lesions include piles (inflamed hemorrhoids), anal fissures, anal cancer or fistulae. Obstetric injury may tear the anal sphincters, and some of these injuries may be occult (undetected). The risk of injury is greatest when labor has been especially difficult or prolonged, when forceps are used, with higher birth weights or when an episiotomy is performed. Only when there is post operative investigation of FI such as endoanal ultrasound is the injury discovered.[2] FI is a much under-reported complication of surgery. The IAS is easily damaged with an anal retractor (especially the Park's anal retractor), leading to reduced resting pressure postoperatively. Since the hemorrhoidal vascular cushions contribute 15% of the resting anal tone, surgeries involving these structures may affect continence status.[2] Partial internal sphincterotomy, fistulotomy, anal stretch (Lord's operation), hemorrhoidectomy or transanal advancement flaps may all lead to FI post operatively, with soiling being far more common than solid FI. The "keyhole deformity" refers to scarring within the anal canal and is another cause of mucus leakage and minor incontinence. This defect is also described as a groove in the anal canal wall, and may occur after posterior midline fissurectomy or fistulotomy, or with lateral IAS defects. Rare causes of traumatic injury to the anal sphincters include military or traffic accidents complicated by pelvic fractures, spine injuries or perineal lacerations, insertion of foreign bodies in the rectum, and sexual abuse.[2] Nontraumatic conditions causing anal sphincter weakness include scleroderma, damage to the pudendal nerves and IAS degeneration of unknown etiology.[3] Radiation induced FI may involve the anal canal as well as the rectum, when proctitis, anal fistula formation and diminished function of internal and external sphincter occur.[2] Irradiation may occur during radiotherapy, e.g. for prostate cancer.
Many people with FI have a generalized weakness of the pelvic floor, especially puborectalis.[3] A weakened puborectalis leads to widening of the anorectal angle, and impaired barrier to stool in the rectum entering the anal canal, and this is associated with incontinence to solids. Abnormal descent of the pelvic floor can also be a sign of pelvic floor weakness. Abnormal descent manifests as descending perineum syndrome (>4 cm perineal descent).[3] This syndrome initially gives constipation, and later FI. The pelvic floor is innervated by the pudendal nerve and the S3 and S4 branches of the pelvic plexus. With recurrent straining, e.g. during difficult labour or long term constipation, then stretch injury can damage the nerves supplying levator ani. The pudendal nerve is especially vulnerable to irreversible damage, (stretch induced pudendal neuropathy) which can occur with a 12% stretch.[2] If the pelvic floor muscles lose their innervation, they cease to contract and their muscle fibres are in time replaced by fibrous tissue, which is associated with pelvic floor weakness and incontinence. Increased pudendal nerve terminal motor latency may indicate pelvic floor weakness. The various types of pelvic organ prolapse (e.g. external rectal prolapse, mucosal prolapse and internal rectal intussusception & solitary rectal ulcer syndrome) may also cause coexisting obstructed defecation.
The rectum needs to be of a sufficient volume to store stool until defecation. The rectal walls need to be "compliant" i.e. able to distend to an extent to accommodate stool. Rectal sensation is required to detect the presence, nature and amount of rectal contents. The rectum must also be able to evacuate its contents fully. There must also be efficient co-ordination of rectal sensation and relaxation of the anal canal.[14] Rectal storage capacity (i.e. rectal volume + rectal compliance) may be affected in the following ways. Surgery involving the rectum (e.g. lower anterior resection, often performed for colorectal cancer), radiotherapy directed at the rectum, and inflammatory bowel disease can cause scarring, which may result in the walls of the rectum becoming stiff and inelastic, reducing compliance. Reduced rectal storage capacity may lead to urge incontinence, where there is an urgent need to defecate as soon as stool enters the rectum, where normally stool would be stored until there was enough to distend the rectal walls and initiate the defecation cycle. Tumors and strictures also may impair reservoir function. Conversely, increased rectal volume (megarectum), may cause fecal loading and overflow FI. Reduced rectal sensation may be a contributory factor.[citation needed] If the sensory nerves are damaged, detection of stool in the rectum is dulled or absent, and the person will not feel the need to defecate until too late. Rectal hyposensitivity may manifest as constipation, FI, or both. Rectal hyposensitivty was reported to be present in 10% of people with FI.[15] Pudendal neuropathy is one cause of rectal hyposensitivity, and may lead to fecal loading/impaction, megarectum and overflow FI.[16] Normal evacuation of rectal contents is 90-100%.[2] If there is incomplete evacuation during defecation, residual stool will be left in the rectum and threaten continence once defecation is finished. This is a feature of people with soiling secondary to obstructed defecation.[17] Obstructed defecation is often due to anismus (paradoxical contraction or relaxation failure of the puborectalis).[2]:38 Whilst anismus is largely a functional disorder, organic pathologic lesions may mechanically interfere with rectal evacuation. Other causes of incomplete evacuation include non-emptying defects like a rectocele. Straining to defecate pushes stool into the rectocele, which acts like a diverticulum and causes stool sequestration. Once the voluntary attempt to defecate, albeit dysfunctional, is finished, the voluntary muscles relax, and residual rectal contents are then able to descend into the anal canal and cause leaking.[2]:37
Drug/mechanism of action | Common examples |
Drugs altering sphincter tone | Nitrates, calcium channel antagonists, beta-adrenoceptor antagonists (beta-blockers), sildenafil, selective serotonin reuptake inhibitors |
Broad spectrum antibiotics | |
Topical drugs applied to anus (reducing pressure) | Glyceryl trinitrate ointment, diltiazem gel, bethanechol cream, botulinum toxin A injection |
Drugs causing profuse diarrhea | Laxatives, metformin, orlistat, selective serotonin reuptake inhibitors, magnesium-containing antacids, digoxin |
Constipating drugs | Loperamide, opioids, tricyclic antidepressants, aluminium-containing antacids, codeine |
Tranquilisers/hypnotics (reducing alertness) | Benzodiazepines, tricyclic antidepressants, selective serotonin reuptake inhibitors, anti-psychotics |
Continence requires conscious and subconscious networking of information from and to the anorectum. Defects/brain damage may affect the central nervous system focally (e.g. stroke, tumor e.g. spinal cord lesions, trauma, multiple sclerosis) or diffusely (e.g. dementia, multiple sclerosis, infection, Parkinson's disease or drug-induced).[1][19] FI (and urinary incontinence) may also occur during epileptic seizures.[20] Dural ectasia is an example of a spinal cord lesion that may affect continence.[21]
Liquid stool is more difficult to control than formed, solid stool. Hence, FI can be exacerbated by diarrhea.[5] Some consider diarrhea to be the most common aggravating factor.[2] Where diarrhea is caused by temporary problems such as mild infections or food reactions, incontinence tends to be short lived. Chronic conditions, such as irritable bowel syndrome or Crohn's disease, can cause severe diarrhea lasting for weeks or months. Diseases, drugs, and indigestible dietary fats that interfere with the intestineal absorption may cause steatorrhea (oily rectal discharge & fatty diarrhea) and degrees of FI. Respective examples include cystic fibrosis, orlistat, and olestra. Postcholecystectomy diarrhea is diarrhea that occurs following gall bladder removal, due to excess bile acid.[citation needed] Orlistat is an anti-obesity (weight loss) drug that blocks the absorption of fats. This may give side effects of FI, diarrhea and steatorrhea.[22]
This may occur when there is a large mass of feces in the rectum (fecal loading), which may become hardened (fecal impaction). Liquid stool elements are able to pass around the obstruction, leading to incontinence. Megarectum (enlarged rectal volume) and rectal hyposensitivity are associated with overflow incontinence. Hospitalized patients and care home residents may develop FI via this mechanism,[5] possibly a result of lack of mobility, reduced alertness, constipating effect of medication and/or dehydration.
Identification of the exact causes usually begins with a thorough medical history, including detailed questioning about symptoms, bowel habits, diet, medication and other medical problems. Digital rectal examination is performed to assesses resting pressure and voluntary contraction (maximum squeeze) of the sphincter complex and puborectalis. Anal sphincter defects, rectal prolapse, and abnormal perineal descent may be detected.[3] Anorectal physiology tests assess the functioning of the anorectal anatomy. Anorectal manometry records the pressure exerted by the anal sphincters and puborectalis during rest and during contraction. The procedure is also able to assess sensitivity of the anal canal and rectum. Anal electromyography tests for nerve damage, which is often associated with obstetric injury. Pudendal nerve terminal motor latency tests for damage to the pudendal motor nerves. Proctography, also known as defecography, shows how much stool the rectum can hold, how well the rectum holds it, and how well the rectum can evacuate the stool. It will also highlight defects in the structure of the rectum such as internal rectal intussusception. Dynamic pelvic MRI, also called MRI defecography is an alternative which is better for some problems but not as good for other problems.[23] Proctosigmoidoscopy involves the insertion of an endoscope (a long, thin, flexible tube with a camera) into the anal canal, rectum and sigmoid colon. The procedure allows for visualization of the interior of the gut, and may detect signs of disease or other problems that could be a cause, such as inflammation, tumors, or scar tissue. Endoanal ultrasound, which some consider to be the gold standard for detection of anal canal lesions,[24] evaluates the structure of the anal sphincters, and may detect occult sphincter tears that otherwise would go unseen.
Functional FI is common.[25] The Rome process published diagnostic criteria for functional FI, which they defined as "recurrent uncontrolled passage of fecal material in an individual with a developmental age of at least 4 years". The diagnostic criteria are, one or more of the following factors present for the last 3 months: abnormal functioning of normally innervated and structurally intact muscles, minor abnormalities of sphincter structure/innervation (nerve supply), normal or disordered bowel habits, (i.e., fecal retention or diarrhea), and psychological causes. Furthermore, exclusion criteria are given. These are factors which all must be excluded for a diagnosis of functional FI, and are abnormal innervation caused by lesion(s) within the brain (e.g., dementia), spinal cord (at or below T12), or sacral nerve roots, or mixed lesions (e.g., multiple sclerosis), or as part of a generalized peripheral or autonomic neuropathy (e.g., due to diabetes), anal sphincter abnormalities associated with a multisystem disease (e.g., scleroderma), and structural or neurogenic abnormalities that are the major cause.[26]
Stool consistency | Cause | First line | Second line |
Diarrhea | Inflammatory | Anti-inflammatory drugs | Constipating drugs |
Pseudodiarrhea | Encopresis | Laxatives | Lavage |
Solid | Pelvic floor | Biofeedback | Sacral nerve stimulation |
Sphincter intact | Sacral nerve stimulation | Lavage | |
Sphincter rupture | Anal repair | Sacral nerve stimulation/Neosphincter | |
Anal atresia | Lavage | Neosphincter | |
Rectal prolapse | Rectopexy | Perineal resection | |
Soiling | Keyhole defect | Lavage | PTQ implant |
FI has an impact on virtually all aspects of peoples' lives, greatly diminishing physical and mental health, and affect personal, social and professional life. Emotional effects may include stress, tearfulness, anxiety, exhaustion, fear of public humiliation, feeling dirty, poor body-image, reduced desire for sex, anger, humiliation, depression, isolation, secrecy, frustration and embarrassment. Some people may need to be in control of life outside of FI as means of compensation. The physical symptoms such as skin soreness, pain and odor may also impact quality of life. Physical activity such as shopping or exercise is often affected. Travel may be affected, requiring careful planning. Working is also affected for most. Relationships, social activities and self-image likewise often suffer.[5]
Symptoms may worsen over time,[1] but FI is generally treatable with conservative management, surgery or both.[2] The success of treatment depends upon the exact causes and how easily these are corrected.[5] Treatment choice depends on the cause and severity of disease, and the motivation and general health of the person effected. Commonly, conservative measures are used together, and if appropriate surgery carried out. Treatments may be attempted until symptoms are satisfactorily controlled. A treatment algorithm based upon the cause has been proposed, including conservative, non-operative and surgical measures (neosphincter refers to either dynamic graciloplasty or artificial bowel sphincter, lavage refers to retrograde rectal irrigation).[2] Conservative measures include dietary modification, drug treatment, retrograde anal irrigation, biofeedback retraining anal sphincter exercises. Incontinence products refer to devices such as anal plugs and perineal pads and garments such as diapers/nappies. Perineal pads are efficient and acceptable for only minor incontinence.[2] If all other measures are ineffective removing the entire colon may be an option.[citation needed]
Dietary modification may be important for successful management.[3] Both diarrhea and constipation can contribute to different cases, so dietary advice must be tailored to address the underlying cause or it may be ineffective or counter productive. In persons with disease aggravated by diarrhea or those with rectal loading by soft stools, the following suggestions may be beneficial: increase dietary fiber; reduce wholegrain cereals/bread; reduce fruit and vegetables which contain natural laxative compounds (rhubarb, figs, prunes/plums); limit beans, pulses, cabbage and sprouts; reduce spices (especially chilli); reduce artificial sweeteners (e.g. sugar free chewing gum); reduce alcohol (especially stout, beer and ale); reduce lactose if there is some degree of lactase deficiency; and reduce caffeine. Caffeine lowers the resting tone of the anal canal and also causes diarrhea. Excessive doses of vitamin C, magnesium, phosphorus and/or calcium supplements may increase FI. Reducing olestra fat substitute, which can cause diarrhea, may also help.[27]
Pharmacological management may include anti-diarrheal/constipating agents and laxatives/stool bulking agents Stopping or substituting any previous medication that causes diarrhea may be helpful in some (see table). There may a benefit from constipating agents in those with coexisting diarrhea. There is little evidence regarding the relative efficacy of medications to other treatments or the use of medications in those with normal stool consitency.[28]
Anti-diarrheal/ constipating agents such as loperamide, codeine phosphate or diphenoxylate with atropine (co-phenotrope) may be used. Loperamide reduces stool weight, decreases bowel motility, rectoanal inhibitory reflex sensitivity and may slightly alter resting anal tone. Codeine phosphate and co-phenotrope are less commonly used because greater side effects.[28] In people who have undergone gallbladder removal, the bile acid sequestrant colestyramine may help minor degrees of FI.[29] Laxatives may be used in elderly people where difficulties are secondary to constipation or fecal impaction (paradoxical diarrhea/ overflow incontinence). A common example is lactulose. Regular use of this laxative is intended to prevent recurrence of impaction. Stool bulking agents may reduce symptoms of obstructed defecation.[28] Bulking agents also absorb water, so may be helpful those with diarrhea. A common side effect is bloating and flatulence. Topical agents to treat and prevent dermatitis may also be used, such as topical antifungals when there is evidence of perianal candidiasis or occasionally mild topical anti-inflammatory medication. Prevention of secondary lesions is carried out by perineal cleansing, moisturization, and use of a skin protectant.[30]
Evacuation aids (suppositories or enemas) e.g. glycerine or bisacodyl suppositories may be prescribed. People may have poor resting tone of the anal canal, and consequently may not be able to retain an enema, in which case transanal irrigation (retrograde anal irrigation) may be a better option, as this equipment utilizes an inflatable catheter to prevent loss of the irrigation tip and to provide a water tight seal during irrigation.[28] A volume of luke warm water is gently pumped into the colon via the anus. People can be taught how to perform this treatment in their own homes, but it does require special equipment. If the irrigation is efficient, stool will not reach the rectum again for up to 48 hours.[31] By regularly emptying the bowel using transanal irrigation, controlled bowel function is often re-established to a high degree in patients with bowel incontinence and/or constipation. This enables control over the time and place of evacuation and development of a consistent bowel routine.[31] However, persistent leaking of residual irrigation fluid during the day may occur and make this option unhelpful, particularly in persons with obstructed defecation syndrome who may have incomplete evacuation of any rectal contents. Consequently, the best time to carry out the irrigation is typically in the evening, allowing any residual liquid to be passed the next morning before leaving the home. Complications such as electrolyte imbalance and perforation are rare. The impact of transanal irrigation varies considerably. Some individuals experience complete control of incontinence, and other report little or no benefit.[31] It has been suggested that if appropriate, people be offered home retrograde anal irrigation.[5]
Biofeedback (the use equipment to record or amplify and then feed back activities of the body) is a commonly used and researched treatment, but the benefits are uncertain.[32] Biofeedback therapy varies in the way it is delivered, but it is unknown if one type has benefits over another.[32]
The role of pelvic floor exercises and anal sphincter exercises in FI is poorly determined. While there may be some benefit they appear less useful than implanted sacral nerve stimulators. These exercises aim to increase the strength of the pelvic floor muscles (mainly levator ani). The anal sphincters are not technically part of the pelvic floor muscle group, but the EAS is a voluntary, striated muscle which therefore can be strengthened in a similar manner. It has not been established whether pelvic floor exercises can be distinguished from anal sphincter exercises in practice by the people doing them. This kind of exercise is more commonly used to treat urinary incontinence, for which there is a sound evidence base for effectiveness. More rarely are they used in FI. The effect of anal sphincter exercises are variously stated as an increase in the strength, speed or endurance of voluntary contraction (EAS).[32]
Electrical stimulation can also be applied to the anal sphincters and pelvic floor muscles, inducing muscle contraction without traditional exercises (similar to transcutaneous electrical nerve stimulation, TENS). The evidence supporting its use is limited, and any benefit is tentative.[33] In light of the above, intra-anal electrical stimulation (using an anal probe as electrode) appears to be more efficacious than intra-vaginal (using a vaginal probe as electrode).[33] Rarely, skin reactions may occur where the electrodes are placed, but these issues typically resolve when the stimulation is stopped. Surgically implanted sacral nerve stimulation may be more effective than exercises, and electrical stimulation and biofeedback may be more effective than exercises or electrical stimulation by themselves.[32] TENS is also sometimes used to treat FI by transcutaneous tibial nerve stimulation.[34]
In a minority of people, anal plugs may be useful for either standalone therapy or in concert with other treatments.[35] Anal plugs (sometimes termed tampons) aim to block involuntary loss of fecal material, and they vary in design and composition.[5] Polyurethane plugs were reported to perform better than those made of polyvinyl-alcohol.[35] Plugs are less likely to help those with frequent bowel movements,[2] and many find them difficult to tolerate.[35]
Surgery may be carried out if conservative measures alone are not sufficient to control incontinence. There are many surgical options, and their relative effectiveness is debated due to a lack of good quality evidence. The optimal treatment regime may be a complex combination of various surgical and non-surgical therapies.[36] The surgical options can be considered in four categories: restoration and improvement of residual sphincter function (sphincteroplasty, sacral nerve stimulation, tibial nerve stimulation, correction of anorectal deformity), replacement / imitation of the sphincter or its function (anal encirclement, SECCA procedure, non-dynamic graciloplasty, perianal injectable bulking agents), dynamic sphincter replacement (artificial bowel sphincter, dynamic graciloplasty), antegrade continence enema (Malone procedure), and finally fecal diversion (e.g. colostomy).[1] A surgical treatment algorithm has been proposed. Isolated sphincter defects (IAS/EAS) may be initially treated with sphincteroplasty and if this fails, the person can be assessed for sacral nerve stimulation. Functional deficits of the EAS and/or IAS (i.e. where there is no structural defect, or only limited EAS structural defect, or with neurogenic incontinence) may be assessed for sacral nerve stimulation. If this fails, neosphincter with either dynamic graciloplasty or artificial anal sphincter may be indicated. Substantial muscular and/or neural defects may be treated with neosphincter initially.[4]
FI is thought to be very common,[1] but much under-reported due to embarrassment. One study reported a prevalence of 2.2% in the general population.[2] It affects people of all ages, but is more common in older adults (but it should not be considered a normal part of aging).[37] Females are more likely to develop it than males (63% of those with FI over 30 may be female).[1]In 2014, the National Center for Health Statistics reported that one out of every six seniors in the U.S. who lived in their own home or apartment had FI. Men and women were equally affected.[38] 45–50% of people with FI have severe physical and/or mental disabilities.[1]
Risk factors include age, female gender, urinary incontinence, history of vaginal delivery (non-Caesarean section childbirth), obesity,[6] prior anorectal surgery, poor general health and physical limitations. Combined urinary and fecal incontinence is sometimes termed double incontinence, and it is more likely to be present in those with urinary incontinence.[39]
Traditionally, FI was thought to be an insignificant complication of surgery, but it is now known that a variety of different procedures are associated with this possible complication, and sometimes at high levels. Examples are midline internal sphincterotomy (8% risk), lateral internal sphincterotomy, fistulectomy, fistulotomy (18-52%), hemorrhoidectomy (33%), ileo-anal reservoir reconstruction, Lower anterior resection, total abdominal colectomy, ureterosigmoidostomy,[6] and anal dilation (Lord's procedure, 0-50%).[40] Some authors consider obstetric trauma to be the most common cause.[41]
While the first mention of urinary incontinence occurs in 1500 BC in the Ebers Papyrus, the first mention of FI in a medical context is unknown.[42] For many centuries, colonic irrigation was the only treatment available. Stoma creation was described in 1776, FI associated with rectal prolapse in 1873 and anterior sphincter repair in 1875. During the mid 20th Century, several operations were developed for instances where the sphincters were intact but weakened.[43] Muscle transpositions using the gluteus maximus or the gracilis were devised, but did not become used widely until later. End-to-end sphincteroplasty is shown to have a high failure rate in 1940. In 1971 Parks and McPartlin first describe an overlapping sphincteroplasty procedure. Biofeedback is first introduced in 1974.[44] In 1975, Parks describes post anal repair, a technique to reinforce the pelvic floor and EAS to treat idiopathic cases. Endoanal ultrasound is invented in 1991, which starts to demonstrate the high number of occult sphincter tears following vaginal deliveries. In 1994, the use of an endoanal coil during pelvic MRI shows greater detail of the anal canal than previously. During the last 20 years, dynamic graciliplasty, sacral nerve stimulation, injectable perianal bulking agents and radiofrequency ablation have been devised, mainly due to the relatively poor success rates and high morbidity associated with the earlier procedures.[43]
Persons with this symptom are frequently ridiculed and ostracized in public. It has been described as one of the most psychologically and socially debilitating conditions in an otherwise healthy individual. In older people, it is one of the most common reasons for admission into a care home. Persons who develop FI earlier in life are less likely to marry and obtain employment. Often, people will go to great lengths to keep their condition secret. It has been termed "the silent affliction" since many do not discuss the problem with their close family, employers or clinicians. They may be subject to gossip, hostility, and other forms of social exclusion.[45][46][47] The economic cost has not received much attention. In the Netherlands, outpatients were reported to have total costs of €2169 annually, and over half of this was productivity loss in work. In the USA, the average lifetime cost (treatment and follow-up) was $17,166 per person in 1996. The average hospital charges for sphincteroplasty was $8555 per procedure. Overall, in the USA, the total charges associated with surgery increased from $34 million in 1998 to $57.5 million in 2003. Sacral nerve stimulation, dynamic graciloplasty and colostomy were all shown to be cost effective.[48]
Doses of 30% - 40% phenylephrine gel may increase anal canal resting pressure to the levels comparable with the normal range.[28] Engineered anal sphincters grown from stem cells have been successfully implanted in mice. New blood vessels developed and the tissue displayed normal contraction and relaxation. In the future, these methods may become part of the management of FI, replacing the need for high morbidity implanted devices such as the artificial bowel sphincter.[49]


text:
Studio Sidekicks
Dance accompanists are an integral part of dance education. The job is multifaceted and challenging. Accompanists must use their experience and instincts to know what music best suits a teacher's needs, and they need to play it well. They play a crucial role in helping dancers understand musicality, all the while seeking to continue developing their own artistry. It's not an easy job, but it's a rewarding and satisfying one for those who are successful.


text:
Former employees of the Mervine Kahn Company, Inc. department store in Rayne are invited to a reunion on Sunday, May 26 which will take place at The Crossing at Mervine Kahn at 113 Louisiana Avenue in Rayne. Lunch will be served at 12 noon and all former employees and family members are invited to attend. […]
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Wounded Warriors Benefit
A Benefit for the Wounded Warrior Foundation will take place on Saturday, May 25th from 8AM -11PM at La Pay E Bas Campground in Eunice. They'll have a jambalaya cook-off at 8AM. $20 per team. An auction will take place at 1PM. There will also be a silent auction, 1 mile walk & ride, washer […]
Vermilionvilles' Weekly Cajun Jam
On Saturday, May 25th from 1-3:30PM, join Vermilionville in Lafayette for their weekly Cajun Jam led by some of the area's finest musicians.. The free jam is held in the Performance Center of Vermilionville and is open to all skill levels. For more info on the jam host, visit the events calendar at www.vermilionville.org
Rendez-Vous Des Cajuns Live at the Liberty Theater
Rendez-Vous Des Cajuns live at the Liberty Theater in Downtown Eunice is every Saturday Night from 6-7:30PM. Performing on May 25th is Don Fontenot and Friends of Louisiana. Admission is $5. For details or a schedule call (337) 457-7389 or visit www.eunice-la.com
Cooyun Duhon Live in Mamou
Come out and laugh your cares away as you hear some of your favorite songs performed with a comical twist. Cooyun Duhon will perform live at the Mamou Recreation Center on May 25th at 7PM. Doors open at 5:30PM. Advanced tickets are $10 and available at the St. Ann's Church Rectory or from any youth […]


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Texas Lakes
- Brenham (10)
- Bryan - College Station (101)
- Cedar Creek Lake (35)
- Denton (2)
- Eagle Mountain Lake (7)
- Ennis (1)
- Frankston (7)
- Frisco (13)
- Glen Rose (7)
- Granbury (20)
- Ladonia (1)
- La Grange (1)
- Lake Bridgeport (5)
- Lake Fork (8)
- Lake Palestine (5)
- Lake Tawakoni (1)
- Lake Texoma (24)
- Lake Weatherford (2)
- Lake Whitney (14)
- Lucas (3)
- Palestine (1)
- Richland Chambers Lake (7)
- Round Top (14)
- Smithville (5)
- Stephenville (1)
- Whitesboro (4)
Recent Texas Lakes Reviews
Perfect weekend!
I stayed at the Holle House for a weekend trip with my 3 sisters & mother. Brenham was a nice central spot for the five of us to meet. We do this 3 times a year, and look for a place where we can sleep comfortably, have at least two bathrooms (we are 5 women!), watch movies together, and cook dinners & breakfasts.
We ended up only using two of the bedrooms (the owner graciously set up the dining room as a 3rd bedroom, with two comfortable looking rollaway twin beds) mother was in the queen bedroom room, and the four sisters shared the two full size beds. It was like being kids again, staying up talking and laughing...just perfect. Beds were VERY comfortable. Even though only one bathroom with a shower, it was no problem for us to share that...having a additional powder room was what was important ;-).
The kitchen had everything we needed to cook our dinners, and the large kitchen was very homey. We enjoyed sitting at the kitchen table playing cards, too. The flat screen tv in the sitting room allowed us to watch our movies. The house was extremely clean. Susan, the owner called a few days before arrival to discuss choices for breakfast that she so thoughtfully provided. We actually couldn't even eat it all! There were also candy dishes full of wrapped chocolates all over the house, and thick fluffy robes left on the beds. Shampoos & soaps, and paper products were also provided. There were more than enough parking for our five cars. The house was just like the pictures showed. There were even fresh flowers!
It was evident that the owner enjoys hosting guests, and that she has gone to great effort to prepare this historical house for guests. As a side note, Brenham was a great choice for us. Our two lunches out, were nice, walking around for several hours downtown, was exactly what we like to do... cute shops, antique stores, etc. and a great grocery store (a large HEB) just a few minutes from the house. Perfect weekend!
Christmas in Glen Rose
Christmas is MAGICAL at this beautiful ranch in Glen Rose---even the second time around! (See our previous review from December, 2012) Hosts Nelson and CJ had decorated evergreen trees at the gate, hung festive jingle bells along the gravel driveway, plus decorated a huge Christmas tree and EVERY room in the house in Christmas splendor. They hit the mark in providing items we appreciated: ample snacks and soft drinks, coffee, luxury towels and linens, extra toiletries---even a Pack-n-Play for our granddaughter. The Guide they sent us ahead of our stay was spot-on with entertainment ideas and restaurant recommendations. We enjoyed the Glen Rose square, and especially Pie Peddlers. Both young grandchildren loved nearby Fossil Rim Wildlife Park. Warm weather enabled us to spend hours traipsing around the ranch and picnicking one afternoon outside. And the fact that these gracious hosts allow us to bring our family dogs? Wow, just wow!
Excellent getaway
Really cool house. Very clean. Very friendly owners. House worked perfectly for us. Awesome kitchen for cooking. Really cool deck. Layout of house worked great for our group with bedrooms on all 3 levels of house. Great place and great value. Highly recommend.


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12 Thrifty Trash to Treasure Crafts
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Wine Cork Apple Stamp
By: Sara Rivka for Creative Jewish Mom
Reuse your wine corks by turning them into custom stamps! With these ideas for wine bottles and corks, you can make a cute apple stamp to use for autumn greeting cards, back to school crafts, and more.
- A wine cork
- Asharp knife
- A red stamp pad
- A black pen
- Some card stock
Using a sharp knife or a craft knife, simply remove from the cork two notches, one for the indentation at the top of the apple and one for the indentation for the bottom of the apple. That's it!
- Stamp carefully, with a towel under the cardstock to enable a better print, and set aside to dry before adding details.
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