Talk:Fecal incontinence/GA1

GA Review

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Reviewer: Jmh649 (talk · contribs) 18:19, 14 December 2012 (UTC)

Status = ON REVIEW

With Doc's permission, I'm going to help out to try to finish up and close out this GA review. Zad68 23:17, 29 January 2013 (UTC)

Thanks...Lesion (talk) 23:30, 29 January 2013 (UTC)

Sure... I am reviewing the older comments from Doc and Bios and seeing if they've been addressed. If they have, I'm going to leave them in the sections labeled for Doc and Bios; if not, I'll bring them forward to here. Then, I'll close off the older sections. This way, we'll all be working off of only this one review section. Zad68 03:57, 30 January 2013 (UTC)

Did more tonight... will probably take a few more nights to get through the first thorough read. Generally looking good, however the article has a tendency to use what looks more like shorthand notes rather than spelling things out completely in words. This is mentioned in tonight's notes. Zad68 05:08, 31 January 2013 (UTC)

Started to do more tonight and I feel the article needs some more general reorganization, I am seeing a lot of cases where I'm reading sections and finding content I am not expecting to find in that section... Zad68 05:12, 1 February 2013 (UTC)

no rush... if u can give specific details of this concern the next time u take this on, then maybe things could be changed... Lesion (talk) 10:57, 1 February 2013 (UTC)

Yes I didn't provide details as I was too tired to go into it last night, but I am actually working on doing some of the re-arranging myself. I started last night but didn't finish... it'll be easier just to show you rather than explain. I'll commit the change to the article and then you can look at it, keep it if you like it or revert if you don't, or take pieces of it, etc. Zad68 14:39, 1 February 2013 (UTC)

Tepi, looking at it more tonight... Some questions about the Classification section:

• "There is no consensus about the best way to classify FI" - sourced to the ASCRS core subjects, but I do not see a discussion of classification in that source document, why am I missing it?

I think was taken from "also in a striking absence of standardization of definitions and quantitation of fecal incontinence" and on re-reading, this does not really support the statement "There is no consensus about the best way to classify FI". Replaced with "NICE Guidelines" p.29 "There is no consensus on methods of classifying the symptoms and causes of faecal incontinence. The most common classifications include:" supports it better.

• Do you have the ASCRS textbook FI chapter? Is there any way I can review it?

Yeah I often download pdfs of textbooks... sometimes this can be done "very cheaply". Alternatively, do you have dropbox or something?

• Also, the Classification section isn't being used for what it should be. In medical articles, the Classification section (if it exists) should be a short paragraph explaining how the symptom or disease ends up with its ICD coding, or if there's more than one coding for it, explanations of the different codings - for example, a disease that affects the small intestine or the large intestine may end up with two different codings. Read Medical classification, and take a look at Crohn's disease for the kind of thing we're looking for in the Classification section.

So tonight's request to you is to bring the Classification section in line with Medical classification. I am actually unsure of where all these different classifications are coming from: leakage character, age, gender... I'm expecting to look at one source document and see a list of these classification types but I'm not seeing it. Where did this list of classifications come from, did you develop it yourself by combining what was found in several sources? Thanks.... Zad68 00:41, 4 February 2013 (UTC)

Source was "NICE guielines" p.29. This is a symptom, or so the sources say, and so should comply with WP:MEDMOS#Symptoms or signs...and so should really ahve a classification seciton at all...currently we have a mix of recommended headings for "Diseases or disorders or syndromes", and also some in the wrong order I notice...this makes the bold sections undesirable, and ideally this content could be moved into the rest of the article somehow...

Suggest 1) merge "prognosis" to end of treatment, 2) possibly merge classification to definitions ? 3) Merge sings and symptoms to end of pathophysiology. I can do this if you are in agreement or maybe u can think of a better way to fit the content into the headings... Lesion (talk) 01:31, 4 February 2013 (UTC)

Template:Multicol-start Recommended:

• Definition
• Differential diagnosis
• Pathophysiology
• Diagnostic approach
• Treatment
• Epidemiology
• History
• Society and culture
• Research
• Other animals

Template:Multicol-break Current article:

• Definition
• Signs and symptoms
• Classification
• Differential diagnosis
• Pathophysiology
• Diagnostic approach
• Treatment
• Prognosis
• Epidemiology
• History
• Society and culture
• Research

Tepi, yes, that's the organization we need to be heading toward. For the source, I'll send you an email so that you can have my email address, will that work? We'll figure out something. Zad68 15:05, 4 February 2013 (UTC)

no problem... I think the rearranged version works fine... Lesion (talk) 17:31, 4 February 2013 (UTC)

Tepi, OK now that I have my hands on Wolff we can move this forward, it's a great resource. The reconfiguration you did earlier today was good. Here's what has to happen next:

1. The content currently in Differential diagnosis is really all Causes. The current WP:MEDMOS doesn't recommend a Causes section for a sign/symptom. We have two choices: 1) Move all that content from Differential diagnosis into Pathophysiology or 2) Ignore all the rules and simply create a Causes section even though it's not recommended by WP:MEDMOS. I am kind of voting for #2, especially because that's exactly what Wolff does.
2. After you move all that content, Differential diagnosis will be empty, and based on my reading of Wolff, it should be about one paragraph with this in it:

Differential diagnosis: FI may present with signs similar to:

• Discharge due to fistule, proctitis, and prolapse
• Pseudoincontinence
• Encopresis
• IBS

and appropriate descriptions of each. Let's try that... Zad68 18:54, 4 February 2013 (UTC)

Confused...I queried what should go in the differential diagnosis section in the past, and was told slightly different by user:Jfdwolff, who stated, "If an article is primarily about a symptom or sign, the sections about differential and diagnostic approach should cover the possible causes (differential) and how physicians will normally distinguish between them (diagnostic approach). An article such as diplopia should contain a referenced list of differential causes, and a section on how diplopia is investigated in routine practice." As such, the section differential diagnosis is intended (or at least the above user thinks so) to be a list of causes, rather than the more strictly correct meaning of differential diagnosis. Please advise... Lesion (talk) 19:15, 4 February 2013 (UTC)

Unless, differential diagnosis is reduced to just a list, and the content moved towards end of pathophysiology... Lesion (talk) 19:20, 4 February 2013 (UTC)

I don't think what JFW is saying is different. There's two types of things we have to get the article to present here: 1) A list of the differential diagnoses of things that FI can look like but aren't FI, and 2) All the different causes of things that are actually FI. For 1) you should give the list of the DDx's and some explanation of their causes - the information a physician would find useful in trying to determine whether a complaint is actually FI or not. If I am understanding it right, soiling due to proctitis wouldn't be coded as FI, and so this should be explained in the DDx section. For 2), that's where your extensive list of causes of FI go. Please tell me if I'm getting the info wrong, all I know about FI is what you've written in this article and what I've read in the sources you've provided. Actually could you get JFDwolff to read this and comment here, just to be sure we get it right? Cheers.... Zad68 19:34, 4 February 2013 (UTC)

The example article given for how a differential diagnosis is supposed to look is not very explanatory, diplopia contains a list of causes of diplopia in a "causes" section and doesn't have a diagnostic approach section so it doesn't clarify this at all... I think I understand that you think DDx section here should be a list of things that are similar to FI, but not FI. I can agree that is the meaning of DDX...and one source suggests already a differential, but these states really also fit the definitions of FI (involuntary loss of bowel contents, flatus, mucus, stool etc). With that vague definition, rectal discharge might be considered FI...Re soiling, in other sources, e.g. NICE guidelines, there is a suggestion that it is a subtype of FI. It's just a mess generally, no standardization of terminology from one source to the next... The article used to go into more detail about "subtypes" but I had to remove most of this due to reliance on 1o sources. Agree all content of current "differential diagnosis" section should be moved to "pathophysiology", probably near the end after the description of physiologic continence. Unsure if those conditions listed by ASRCS as differential are truly outside the definitions of FI. At the risk of original thought, we should probably follow the source... Lesion (talk) 19:52, 4 February 2013 (UTC)

I agree that the diplopia did not really seem to be a good example. Maybe JFDwolff was just saying how "it should be" but isn't? I'd actually like him to comment here if you can get him to... Is one of the sources you are using clearly more authoritative than the other? If so just go with how the most authoritative source does it. The Wolff source really seems to lay this out clearly. FI is a chronic problem with the neurological or muscular sensation and/or control of the anal plug area, caused by many possible things. FI isn't temporary loss of control due to terrible diarrhea, and FI isn't soiling due to proctitis, as far as I can tell from my reading of Wolff, are you not reading it the same way? Zad68 20:02, 4 February 2013 (UTC)

Contacted him. That is a good point, and I see one of the definitions qualifies with a temporal component too: "the recurrent uncontrolled passage of fecal material in an individual ..." This could be considered to exclude discharge and even encopresis, as this I think mostly refers to overflow incontinence in childhood which is transient and not permanent. I'm not confident to say which source is most authoritative. Since ASCRS is the one that actually mentions a differential, and contradictions by other sources are only by extension and not explicitly implied, I've just gone ahead and moved the sections... Lesion (talk) 20:12, 4 February 2013 (UTC)

Great! I took a look at the reorg, and yeah, now it's making more sense to me... super! More later.... Zad68 20:15, 4 February 2013 (UTC)

(←) The concept of "differential diagnosis" of symptoms is used in different ways: it could mean both alternative but similar symptoms ("the differential of angina could be oesophageal spasm"), but technically it should refer to the possible causes for these symptoms ("the differential of chest pain is angina, oesophageal spasm, acid reflux, costochondritis etc"). I'd say an article would need to cover both aspects to be complete. JFW | T@lk 13:27, 5 February 2013 (UTC)

Thanks for comment. Using this article as an example, does the ddx section contain the right kind of content? (currently symptoms/sings similar to FI but not technically FI) Or should all the "causes of FI" we just moved to pathophysiology be put back into ddx? Lesion (talk) 14:16, 5 February 2013 (UTC)

I think differential diagnosis of a symptom compared to differential diagnosis of a specific condition was confusing us. The differential of a symptom is a list of its possible causes and how to separate them, whereas the differential of a specific condition is a list of other conditions which may be similar and need to be distinguished... Lesion (talk) 10:55, 6 February 2013 (UTC)

I've reviewed a bunch more sources and there are some issues to address, please check out the Sourcing section. Zad68 03:53, 22 February 2013 (UTC)

More from Biosthmors

• Shouldn't most stuff in Fecal_incontinence#Normal_physiology be moved elsewhere? Pathophysiology sections describe only what directly causes the topic of the article, in my opinion. Biosthmors (talk) 00:52, 6 February 2013 (UTC)

• Yeah I've been mulling that over in my mind... I generally like "backgrounder" information, especially in a general encyclopedia not targeted specifically to a medical audience, but that section is really very large. I was considering asking for it to be cut down by quite a bit. It might make a useful addition to another article. Unless you can think of another place where it could go here in this article? Zad68 00:55, 6 February 2013 (UTC)

• It is maybe excessive detail when we could just nest defecation for this subsection? Much of the content is about defecation generally, rather than continence, if that makes sense. Lesion (talk) 01:45, 6 February 2013 (UTC)

• Tepi can you consider, for this article, cutting down that large discussion into like maybe 3-4 sentences of backgrounder? Pull just the information most relevant to the causes of FI. But that was a lot of good work you put into that section, see if there's another article you can merge it into. Adding -- defecation is in terrible shape, please use the content you developed here in that article, it would really help it. Zad68 04:10, 6 February 2013 (UTC)

• Reduced to paragraph length...probably I can reduce it some more later. Lesion (talk)

GA table

Rate	Attribute	Review Comment
1. Well-written:
	1a. the prose is clear, concise, and understandable to an appropriately broad audience; spelling and grammar are correct.	Close paraphrase issue, verifiability issue
	1b. it complies with the Manual of Style guidelines for lead sections, layout, words to watch, fiction, and list incorporation.
2. Verifiable with no original research:
	2a. it contains a list of all references (sources of information), presented in accordance with the layout style guideline.	References section exists
	2b. reliable sources are cited inline. All content that could reasonably be challenged, except for plot summaries and that which summarizes cited content elsewhere in the article, must be cited no later than the end of the paragraph (or line if the content is not in prose).
	2c. it contains no original research.
3. Broad in its coverage:
	3a. it addresses the main aspects of the topic.
	3b. it stays focused on the topic without going into unnecessary detail (see summary style).
	4. Neutral: it represents viewpoints fairly and without editorial bias, giving due weight to each.
	5. Stable: it does not change significantly from day to day because of an ongoing edit war or content dispute.
6. Illustrated, if possible, by media such as images, video, or audio:
	6a. media are tagged with their copyright statuses, and valid non-free use rationales are provided for non-free content.
	6b. media are relevant to the topic, and have suitable captions.	Infobox image is normal function and does not depict FI, I know you're working on getting permission for a FI one, but the one that's there is adequate
	7. Overall assessment.

Notes

Note -- the number in parentheses before each item corresponds with the numbering of the GA requirement listed in the GA Table above.

MOS compliance

• (1b) Duplicate links: trauma(tically), rectal discharge, fistulae, obstetric, fistulotomy, anal fistula, rectal prolapse, obstructed defecation, IBS, fecal loading, stroke, MS, dementia, SSRI, antacids, trycyclic antidepressants, piles, abnormal perineal descent, Pudendal nerve terminal motor latency, Endoanal ultrasound, functional, laxative, olestra, loperamide, impaction, dyanmic graciloplasty, sphincterotomy, fistulotomy, hemorrhoidectomy, low anterior rectal resection, colectomy

fixed... Lesion (talk) 14:29, 30 January 2013 (UTC)

General

• Avoid doing things like "symptom(s)" when you mean "symptom or symptoms", it's not encyclopedic, you can generally just use the plural.

 Done

Lead

• (1a) FI is not untreatable and almost all people can be helped. -- consider: FI is generally treatable.

 Done

• (1) Lead currently appears unbalanced, as there is too much about the social stigma relative to the proportion of coverage of this in the article.

Removed sent "Topics relating to feces are taboo" or something, wasn't contributing much.

• (1) Lead should be 3-4 paragraphs, reorganize

 Done

• (1) "which is described as devastating" -- if you semi-quote something here (which is described as... who is describing?) you have to name where it's coming from. But, "devastating" is an emotive rather than informative word, can you describe in exactly what ways it is devastating?

It was from Yamada's Textbook of Gastroenterology, p1728 "Unfortunately, physicians may not always appreciate the devastating consequences of FI because patients are often embarrassed to discuss their symptoms." Removed devastating and replaced with less emotive description from society and culture section "one of the most psychologically and socially debilitating conditions in an otherwise healthy individual". Lesion (talk) 14:53, 30 January 2013 (UTC)

• (1) FI is generally treatable.[2] There are many different treatments available and management is related to the specific cause(s). Management may be an individualized mix of dietary, pharmacologic and surgical measures. It has been suggested that health care professionals are often poorly informed about treatment options.[2] They may fail to recognize the impact of FI, which is described as one of the most psychologically and socially debilitating conditions in an otherwise healthy individual.[3] -- consider replacing this whole lead paragraph with: FI is one of the most psychologically and socially debilitating conditions in an otherwise healthy individual, but it is generally treatable. Management can be achieved through an individualized mix of dietary, pharmacologic and surgical measures. Health care professionals are often poorly informed about treatment options, and may fail to recognize the impact of FI.

 Done

Definition

• Can you combine the five separate definitions into one general one, something like, "Fecal incontience is generally defined as the inability to voluntarily control the passage of bowel contents through the anal canal and expel it at a socially acceptable location and time." I think it'd be better to combine the imporatant features common to the definitions rather than to just give an unorganized list.
• FI can be divided into those people who experience a defecation urge before leakage, termed urge incontinence, and those who experience no sensation before leakage, termed passive incontinence or soiling. -- I can't find this in the cited NICE source, I don't see "urge incontinence" in the text at all, can you help me find this? ... oh wait maybe I have to search for "urge faecal incontinence"

p.29 Lesion (talk) 15:17, 30 January 2013 (UTC)

• It has been suggested that once continence to flatus is lost, it is rarely restored. -- Why "it has been suggested", can you just say "Once continence to flatus is lost..."? Why not if not?

reworded, but not particularly able to explain why since our source does not either ... "Identification of which symptoms trouble the patient and what can be achieved by repair is essential. Thus continence to flatus can rarely be restored once lost and dietary modification with medication may be more helpful."

• Fecal leakage is a related topic to rectal discharge... fecal mass to be retained in the rectum. -- Is this whole part still on the topic of FI?

Having studied both FI and rectal discharge a little bit, I feel there is some overlap here and a link to the (currently poor) rectal discharge page is necessary. E.g. both topics tend to list lesions that mechanically prevent anal canal closure, such as fissures. With regards "fecal leakage" this is a subtype of FI...

• Several severity scales have been suggested. the most commonly used are mentioned below. -- can you just get rid of "the most commonly used are mentioned below.", again "below" isn't desired

 Done

• over the age of 4 -- 4 should be spelled out "four" here per WP:MOSNUM

 Done

• (+/- urgency) -- do you mean "with or without"? Use words

 Done

• The Park's incontinence score uses 4 categories, -- it says 4 here but then goes on to list 6 things; 4 --> "four"

 Done I can see why you thought this, it was v confusing before, reworded now.

• This Severity scales section is confusing and needs clarifying

 Done

• Other severity scales include... -- how common are the Wexner and Park's scales relative to all these others?

Kaiser and the ASCRS textbook seem to suggest that are more commonly used than those listed at the end of the section.

• Requested citation for "Solid stool incontinence may be called complete (or major) incontinence, and anything less as partial (or minor) incontinence" partially supported by ASCRS textbook, p.653 "Partial incontinence may be defined as uncontrolled passage of gas and/or liquids and complete incontinence as the uncontrolled passage of solid feces."  Done Lesion (talk) 15:42, 17 February 2013 (UTC)

Differential diagnosis

• symptoms(s) --> symptoms

 Done

• "prtorusion" -- is protrusion meant?

 Done

• If there is a major underlying cause, this may also give rise to specific signs and symptoms in addition to the ones above (e.g. prtorusion of mucosa in external rectal prolapse). -- avoid using page-relative directions like "to the ones above"; consider rewording this as, Any major underlying cause will produce additional signs and symptoms, such as protrusion of mucosa in external rectal prolapse.

 Done

• (1a) Possible close paraphrase/plagiarism problem:

Source = Focal defects (e.g. keyhole deformity after previous anorectal surgery) can therefore result in significant symptoms despite a seemingly normal pressure profile.

Article = Focal defects (e.g. keyhole deformity) can therefore result in significant symptoms despite a seemingly normal anal canal pressures.

Reword "This means that even with normal anal canal pressure, focal defects such as the keyhole deformity can be the cause of substantial symptoms"

• (1a) FI (and urinary incontinence) may also occur during seizures. -- sourced to Kaiser but can't find "seizures" in the source.

Added supporting citation for FI during seizure.

• (1a) Nontraumatic conditions interfering with anal canal function include scleroderma... - the source is more specific and says these are causes of anal sphincter weakness, can this be made more specific?

Reword "Nontraumatic conditions which may cause anal sphincter weakness include scleroderma ..." Lesion (talk) 13:52, 30 January 2013 (UTC)

Pathophysiology

• (1b) Some believe the anorectal angle is one of the most important contributors to continence. -- "Some believe" is WP:WEASEL. I'm not quite seeing this in the source... it talks about the angle but I'm not seeing it stating "one of the most important important contributors", can you help me find where it says this?

Couldn't find it. Upon rereading parts of The ASCRS textbook, it seems that opinions are divided as to how important the anorectal angle is in continence. Removed this sentence.Lesion (talk) 14:09, 30 January 2013 (UTC)

Treatment

• (1a) Table - four blank lines under Solid, should these cells be merged?

I'll find out how to do this...

 Done

• Other measures - Doc's concern about too much content regarding pelvic floor exercises

this issue was resolved and the section rewritten?

• (1a) Dietary modification may be central to successful management -- "may be central": "may be" is a hedge, "central" is emphatic, and together they clash. For which people is it central? Qualify

This sent used to read "some believe that dietary modificiation is central..." but this was weasel... I could change central -> important.

• A surgical treatment algorithm has been proposed. -- Is this just Wexner's own proposal? Has this proposal been endorsed or mentioned anywhere else? If it's just Wexner's idea and isn't generally accepted, and Wexner isn't a particularly notable leader in the field, it's probably undue to mention it.

This is based on the diagram on p 116 of "Coloproctology". The text refers to the diagram with "Depending on the underlying condition, various surgical treatment modalities can be offered and a new treatment alogrithm has evolved (Fig. 9.1)." with no reference. Even if it was just Wexner's idea, I think there is an eponymous severity scale, so maybe they are a notable person. This reads badly due to conversion from list to prose, and may be out of date since it does not include some options. Does it contribute significantly to warrant inclusion? Lesion (talk) 15:11, 30 January 2013 (UTC)

• (1a) Symptoms may worsen over time, but is not untreatable and almost all people are helped with conservative management, surgery or both. -- I thought FI itself was a symptom, can a symptom have symptoms? also verb agreement and double-negative, I do not see how "worsen over time" is connected to "treaments and management are available", and the wording here sounds vaguely non-encyclopedic and more "So you have fecal incontinence" brochure; consider something like: FI may worsen over time. Conservative management strategies and surgical treatments are effective and have high rates of success.

Um... as per WP:MEDMOS#Symptoms or signs it is not recommended to have a section called "signs and symptoms". This section was largely taken from the section "symptoms" on Kaiser. I don't really think this is a problem, but it could potentially be merged with classification by symptom ? I think worsen over time refers to the symptom worsening without treatment. The sentence used to qualify "without treatment" but it was a bit clumsy sounding so I think someone took it out. Lesion (talk) 15:02, 30 January 2013 (UTC)

External links

• Doc to review the ones left

Remaining link is to International Continence Society, international in scope and notable with its own page. I think this is fine... Lesion (talk) 14:35, 31 January 2013 (UTC)

Media

• Y Copyright status OK

Sourcing

Sources table

In this table: Source lists the source as cited in the article Seems WP:RS? means, "Does this source appear to meet WP:RS for reliable sourcing?" Use OK? means, is the source used appropriately in the article? For the review, a few selected sources will be spot-checked to ensure they aren't plagiarized and support the article content. ? indicates the source was not spot-checked. Notes will summarize problems found and what needs to be done to fix them Source Seems WP:RS? Use OK? Notes <ref name="Yamada textbook">{{cite book|editors=Tadataka Yamada, David H. Alpers, et al.|title=Textbook of gastroenterology|year=2009|publisher=Blackwell Pub.|location=Chichester, West Sussex|isbn=978-1-4051-6911-0|edition=5th ed.|pages=1717–1744}}</ref> Y ? Some issues <ref name="ASCRS textbook">{{cite book|editors=Bruce G. Wolff et al.|title=The ASCRS textbook of colon and rectal surgery|year=2007|publisher=Springer|location=New York|isbn=0-387-24846-3|pages=653–664}}</ref> Y ? <ref name="Coloproctology textbook">{{cite book|last=Wexner|first=edited by Andrew P. Zbar, Steven D.|title=Coloproctology|year=2010|publisher=Springer|location=New York|isbn=978-1-84882-755-4|pages=109–119}}</ref> Y ? <ref name="ASCRS core subjects FI">{{cite web|last=Kaiser|first=Andreas M|title=ASCRS core subjects: fecal incontinence|url=http://www.fascrs.org/physicians/education/core_subjects/2009/fecal_incontinence/|publisher=ASCRS|accessdate=29 October 2012}}</ref> Y ? N Close paraphrase/plagiarism problem This is resolved now, see Talk:Fecal incontinence/GA1#Differential diagnosis above. Lesion (talk) <ref name="4th ICI">{{cite book|editors=Paul Abrams et al.|title=Incontinence : 4th International Consultation on Incontinence, Paris, July 5-8, 2008|year=2009|publisher=Health Publications|location=[Paris]|isbn=0-9546956-8-2|edition=4th ed.|page=35|chapter=Epidemiology of Urinary (UI) and Faecal (FI) Incontinence and Pelvic Organ Prolapse (POP)}}</ref> Y ? Y <ref>{{cite web|last=Kaneshiro|first=Neil|title=Encopresis|url=http://www.nlm.nih.gov/medlineplus/ency/article/001570.htm|publisher=Medline Plus|accessdate=2 July 2012}}</ref> Y Y Y after a little fixing <ref name="Shamliyan 2009">{{cite journal|last=Shamliyan|first=TA|coauthors=Bliss, DZ; Du, J; Ping, R; Wilt, TJ; Kane, RL|title=Prevalence and risk factors of fecal incontinence in community-dwelling men.|journal=Reviews in gastroenterological disorders|date=2009 Fall|volume=9|issue=4|pages=E97-110|pmid=20065920}}</ref> Y Y <ref>{{cite book|editors= Paul Abrams et al.|title=Incontinence : 4th International Consultation on Incontinence, Paris, July 5-8, 2008|year=2009|publisher=Health Publications|location=[Paris]|isbn=0-9546956-8-2|edition=4th ed.|page=255|chapter=Pathophysiology of Urinary Incontinence, Faecal Incontinence and Pelvic Organ Prolapse}}</ref> Y ? <ref name="Nusrat 2012">{{cite journal|last=Nusrat|first=S|coauthors=Gulick, E; Levinthal, D; Bielefeldt, K|title=Anorectal dysfunction in multiple sclerosis: a systematic review.|journal=ISRN neurology|year=2012|volume=2012|pages=376023|pmid=22900202}}</ref> Y ? N placement of ref looks like an WP:INTEGRITY problem Grouped this ref and the "NICE guidelines" ref together at end of this section, which is all supported by NICE guidelines, including MS + FI link, I just came across this paper and thought it useful to include. Lesion (talk) <ref name="NICE guidelines">{{cite book|last=(UK)|first=National Collaborating Centre for Acute Care|title=Faecal incontinence the management of faecal incontinence in adults|year=2007|publisher=National Collaborating Centre for Acute Care (UK)|location=London|isbn=0-9549760-4-5|url=http://www.ncbi.nlm.nih.gov/books/NBK50665/}}</ref> Y ? <ref name="Rodrigues 2012">{{cite journal|last=Rodrigues|first=ML|coauthors=Motta, ME|title=Mechanisms and factors associated with gastrointestinal symptoms in patients with diabetes mellitus.|journal=Jornal de pediatria|date=2012 Jan-Feb|volume=88|issue=1|pages=17–24|pmid=22344626}}</ref> Y ? <ref name="Goldstone 2004">{{cite journal|last=Goldstone|first=SE|coauthors=Welton, ML|title=Anorectal sexually transmitted infections in men who have sex with men--special considerations for clinicians.|journal=Clinics in colon and rectal surgery|date=2004 Nov|volume=17|issue=4|pages=235–9|pmid=20011265|pmc=2780055}}</ref> N N This is an older source, 2004, and the use of it in the article takes the results of a very small (N=14 in the study group) prospective cohort study and generalizes it too much, far beyond what the source does. It's not important to the article overall, consider just deleting it. See also Talk:Fecal incontinence/GA1#Encyclopedic?. This issue initially raised by Biosthmors. I have already searched for a more up to date reference discussing this issue, seems there has been no further investigation since these small primary studies (1993 and 1997), which are then cited by this secondary source in 2004. Un-PC topic to research I suspect. Suggest (1) make an exception to MEDDATE or (2) remove the supported content based on lack of Notability. Personally I feel option 2 may lead to future editors to cite the primary sources, and even present their results in a misleading manner. This was the case when I first started on this article (see Talk:Fecal incontinence#Innapropriate/misleading language regarding risk of FI with anoreceptive intercourse?). Lesion (talk) <ref name="hoffmann 1995">{{cite journal|last=Hoffmann|first=BA|coauthors=Timmcke, AE; Gathright JB, Jr; Hicks, TC; Opelka, FG; Beck, DE|title=Fecal seepage and soiling: a problem of rectal sensation.|journal=Diseases of the colon and rectum|date=1995 Jul|volume=38|issue=7|pages=746–8|pmid=7607037}}</ref> N N Puzzled by this one, this is a 1995 primary study of seepage, I don't at all see how it supports the content it's applied to ("The rectum needs to be of a sufficient volume..."). Isn't there an up-to-date secondary source that can be used for this general info? Thought I got rid of all 1o already. Pending. Lesion (talk) <ref name="Burgell 2012">{{cite journal|last=Burgell|first=Rebecca E|coauthors=Scott, S Mark|title=Rectal Hyposensitivity|journal=Journal of Neurogastroenterology and Motility|date=1 January 2012|volume=18|issue=4|pages=373|doi=10.5056/jnm.2012.18.4.373}}</ref> Y Y <ref name="Rao 2004">{{cite journal|last=Rao|first=SS|title=Pathophysiology of adult fecal incontinence.|journal=Gastroenterology|date=2004 Jan|volume=126|issue=1 Suppl 1|pages=S14-22|pmid=14978634}}</ref> ? ? 2004 is a little old, can you find something more recent? pending. Lesion (talk) <ref>{{cite journal|last=Rao|first=SS|coauthors=Ozturk, R; Stessman, M|title=Investigation of the pathophysiology of fecal seepage.|journal=The American journal of gastroenterology|date=2004 Nov|volume=99|issue=11|pages=2204–9|pmid=15555003|doi=10.1111/j.1572-0241.2004.40387.x}}</ref> N 2004 primary ? This is from a 2004 primary study, can you find an up-to-date review that covers the same content? pending. Lesion (talk) <ref name="Salat-Foix 2012">{{cite journal|last=Salat-Foix|first=D|coauthors=Suchowersky, O|title=The management of gastrointestinal symptoms in Parkinson's disease.|journal=Expert review of neurotherapeutics|date=2012 Feb|volume=12|issue=2|pages=239–48|pmid=22288679}}</ref> Y N The only thing this ref supports is Parkinson's but it appears to be used for a number of other things. Rearranged refs to better represent the content. "ASCRS core subjects" supported this whole section, with this citation supporting Parkinson's only. Grouped both refs at the end of the sentence. Lesion (talk) <ref name="Bharucha 2010">{{cite journal|last=Bharucha|first=Adil E.|title=Incontinence: An Underappreciated Problem in Obesity and Bariatric Surgery|journal=Digestive Diseases and Sciences|date=2 June 2010|volume=55|issue=9|pages=2428–2430|pmid=20521110|doi=10.1007/s10620-010-1288-0}}</ref> N ? N This is an editorial and per WP:MEDRS falls under "expert opinion", the lowest-quality type of source, can you source this to a reputable textbook? Replaced with a PubMed central review from 2012... pmid=22363917. <ref name="Abdool 2012">{{cite journal|last=Abdool|first=Z|coauthors=Sultan, AH; Thakar, R|title=Ultrasound imaging of the anal sphincter complex: a review.|journal=The British journal of radiology|date=2012 Jul|volume=85|issue=1015|pages=865–75|pmid=22374273}}</ref> Y Y <ref name="Rome iii">{{cite web|title=Rome III Diagnostic Criteria for Functional Gastrointestinal Disorders|url=http://www.romecriteria.org/criteria/|publisher=Rome Foundation|accessdate=3 November 2012}}</ref> ? <ref>[http://www.ncbi.nlm.nih.gov/books/NBK50649/ Food/drink which may Exacerbate Faecal Incontinence in Patients who Present with Loose Stools or Rectal Loading of Soft Stool] 2007. National Collaborating Centre for Acute Care.</ref> ? <ref name="Cheetham 2003">{{cite journal|last=Cheetham|first=M|coauthors=Brazzelli, M; Norton, C; Glazener, CM|title=Drug treatment for faecal incontinence in adults.|journal=Cochrane database of systematic reviews (Online)|year=2003|issue=3|pages=CD002116|pmid=12917921|doi=10.1002/14651858.CD002116}}</ref> ? <ref>{{cite book|last=Romano|first=[edited by] Carlo Ratto, Giovanni B. Doglietto ; forewords by A.C Lowry, L. Paahlman, G.|title=Fecal incontinence : diagnosis and treatment|year=2007|publisher=Springer|location=Milan|isbn=88-470-0637-6|edition=1. Ed.|page=313}}</ref> ? <ref name="Gray 2012">{{cite journal|last=Gray|first=M|coauthors=Beeckman, D; Bliss, DZ; Fader, M; Logan, S; Junkin, J; Selekof, J; Doughty, D; Kurz, P|title=Incontinence-associated dermatitis: a comprehensive review and update.|journal=Journal of wound, ostomy, and continence nursing : official publication of The Wound, Ostomy and Continence Nurses Society / WOCN|date=2012 Jan-Feb|volume=39|issue=1|pages=61–74|pmid=22193141}}</ref> ? <ref name="Norton 2012">{{cite journal|last=Norton|first=C|coauthors=Cody, JD|title=Biofeedback and/or sphincter exercises for the treatment of faecal incontinence in adults.|journal=Cochrane database of systematic reviews (Online)|date=2012 Jul 11|volume=7|pages=CD002111|pmid=22786479}}</ref> ? <ref name="Hosker 2007">{{cite journal|last=Hosker|first=G|coauthors=Cody, JD; Norton, CC|title=Electrical stimulation for faecal incontinence in adults.|journal=Cochrane database of systematic reviews (Online)|date=2007 Jul 18|issue=3|pages=CD001310|pmid=17636665}}</ref> ? <ref name="Norton 2012">{{cite journal|last=Norton|first=C|coauthors=Cody, JD|title=Biofeedback and/or sphincter exercises for the treatment of faecal incontinence in adults.|journal=Cochrane database of systematic reviews (Online)|date=2012 Jul 11|volume=7|pages=CD002111|pmid=22786479|doi=10.1002/14651858.CD002111.pub3}}</ref> ? <ref name="Deutekom 2012">{{cite journal|last=Deutekom|first=M|coauthors=Dobben, AC|title=Plugs for containing faecal incontinence.|journal=Cochrane database of systematic reviews (Online)|date=2012 Apr 18|volume=4|pages=CD005086|pmid=22513927|doi=10.1002/14651858.CD005086.pub3}}</ref> ? <ref name="Brown 2010">{{cite journal|last=Brown|first=SR|coauthors=Wadhawan, H; Nelson, RL|title=Surgery for faecal incontinence in adults.|journal=Cochrane database of systematic reviews (Online)|date=2010 Sep 8|issue=9|pages=CD001757|pmid=20824829}}</ref> ? <ref name="Shah 2012">{{cite journal|last=Shah|first=BJ|coauthors=Chokhavatia, S; Rose, S|title=Fecal Incontinence in the Elderly: FAQ.|journal=The American journal of gastroenterology|date=2012 Nov|volume=107|issue=11|pages=1635–46|pmid=22964553}}</ref> ? <ref name="Shamliyan 2007">{{cite journal|last=Shamliyan|first=T|coauthors=Wyman, J; Bliss, DZ; Kane, RL; Wilt, TJ|title=Prevention of urinary and fecal incontinence in adults.|journal=Evidence report/technology assessment|date=2007 Dec|issue=161|pages=1–379|pmid=18457475}}</ref> ? <ref name="Rieger 1999">{{cite journal|last=Rieger|first=N|coauthors=Wattchow, D|title=The effect of vaginal delivery on anal function.|journal=The Australian and New Zealand journal of surgery|date=1999 Mar|volume=69|issue=3|pages=172–7|pmid=10075354}}</ref> ? <ref name="Ommer 2008">{{cite journal|last=Ommer|first=A|coauthors=Wenger, FA; Rolfs, T; Walz, MK|title=Continence disorders after anal surgery--a relevant problem?|journal=International journal of colorectal disease|date=2008 Nov|volume=23|issue=11|pages=1023–31|pmid=18629515}}</ref> ? <ref name="Treatment of FI thesis">{{cite book|last=Briel|first=Johan Willem|title=Treatment of faecal incontinence|year=2000|publisher=[The Author]|location=[S.l.]|isbn=90-90-13967-2|pages=10–12|chapter=1}}</ref> ? <ref name="Surgery for FI chapter">{{cite book|=editors=Paul Abrams et al.|title=Incontinence : 4th International Consultation on Incontinence, Paris, July 5-8, 2008|year=2009|publisher=Health Publications|location=[Paris]|isbn=0-9546956-8-2|edition=4th ed.|page=1387|chapter=Surgery for fecal incontinence}}</ref> ? <ref>{{cite journal|last=Engel|first=BT|coauthors=Nikoomanesh, P; Schuster, MM|title=Operant conditioning of rectosphincteric responses in the treatment of fecal incontinence.|journal=The New England journal of medicine|date=1974 Mar 21|volume=290|issue=12|pages=646–9|pmid=4813725}}</ref> ? <ref>{{cite web|last=Norton|first=Nancy J.|title=Barriers on Diagnosis and Treatment; Impact of Fecal and Urinary Incontinence on Health Consumers – Barriers on Diagnosis and Treatment – A Patient Perspective|url=http://www.aboutincontinence.org/site/about-incontinence/daily-living-with-incontinence/barriers-on-diagnosis-and-treatment|publisher=International Foundation for Functional Gastrointestinal Disorders (IFFGD)|accessdate=1 January 2013}}</ref> ? <ref>{{cite web|last=Ranganath|first=Sonia|title=Fecal Incontinence|url=http://emedicine.medscape.com/article/268674-overview#a0199|publisher=WebMD LLC|accessdate=1 January 2013|coauthors=Tanaz R Ferzandi}}</ref> ? <ref>{{cite journal|last=Bliss|first=DZ|coauthors=Norton, C|title=Conservative management of fecal incontinence.|journal=The American journal of nursing|date=2010 Sep|volume=110|issue=9|pages=30–8; quiz 39–40|doi=10.1097/01.NAJ.0000388262.72298.f5.|pmid=20736708}}</ref> ? <ref>{{cite book|editors= Paul Abrams et al.|title=Incontinence : 4th International Consultation on Incontinence, Paris, July 5-8, 2008|year=2009|publisher=Health Publications|location=[Paris]|isbn=0-9546956-8-2|page=1685|edition=4th ed.|chapter=Economics of urinary and faecal incontinence, and prolapse}}</ref> ? <ref>{{cite journal|last=Koch|first=Kenneth L|title=Tissue engineering for neuromuscular disorders of the gastrointestinal tract|journal=World Journal of Gastroenterology|date=1 January 2012|volume=18|issue=47|pages=6918|doi=10.3748/wjg.v18.i47.6918|pmid=23322989|pmc=PMC3531675}}</ref> ?

Post-GA suggestions

• Are we near an end here? The page is 90kb and it's been open nearly three months. Any GA criteria surely would've been met by now given all the detail the review has. Wizardman 17:01, 7 March 2013 (UTC)

Just a few references left to check I think... Lesion (talk) 18:01, 7 March 2013 (UTC)

It's been slow moving but we're still working on it, if it's not causing any trouble would you mind us leaving it open to work on it? This is an article which is hard to find editors to work on or do GA reviews for... Zad68 22:33, 7 March 2013 (UTC)

Yes would like to thank Zad68 for all his excellent comments. There is no time limit really. And taking an article from stub to GA is a major undertaking. Doc James (talk · contribs · email) (if I write on your page reply on mine) 03:11, 8 March 2013 (UTC)

I'm fine leaving it open a bit longer. Just not used to reviews going into so much detail. Not that I'm complaining, clearly that's going to make the article that much better. Wizardman 05:17, 10 March 2013 (UTC)

Yes we have high standards at WP:MED :-) Doc James (talk · contribs · email) (if I write on your page reply on mine) 16:08, 10 March 2013 (UTC)

I was thinking about this myself, simply because this page is a little bit long (which just shows progress)! What if we all decided to close this review, but immediately open another to have a fresh start and a clean GA review to get messy again? =) It may sound silly, but I know I am more willing to leave comments somewhere clean rather than onto a review that is long like this one. Lesion, do you mind withdrawing and starting another GA review, or does that sound de-motivating? For me, it sounds motivating but opinions could easily differ. I'd also like to prevent more random people from popping up and griping about the duration of the review, depsite the article improvement, which should always be the main goal. (That happened to Sasata and I over at Talk:Malaria/GA2.) Or maybe this is a bad suggestion of mine because maybe we really are that close and detailed review is no longer necessary. Biosthmors (talk) 20:13, 10 March 2013 (UTC)

I would be ok with either scenario...would prefer to finish this as I started it...the user who started this thread is also not out of order by commenting - I think it says somewhere GA reviews should only last 1 week? As to whether this RV is near completion, there is a suggestion that zad is going to work through every source. Issues are being raised by this thorough process, so it could be argued that this is worth while, and also probably reflects the guidelines for how to review, see WP:GACN#(1) Well written: "Mistakes to avoid Not checking at least a substantial proportion of sources to make sure that they actually support the statements they're purported to support. (Sources should not be "accepted in good faith": for example, nominators may themselves have left prior material unchecked by assuming good faith."

The only other RV I saw being done was (Talk:Hemorrhoid/GA1), which I was barely involved in, but did seem to be less thorough. Perhaps because it was written from the start by an experienced editor, and here the article started off mostly based on primary sources... Lesion (talk) 22:07, 10 March 2013 (UTC)

Archived previous review items

Archived previous review items from Doc James and Biosthmors, mostly addressed, anything not addressed brought foward

Review started by Doc James Initial comments Large section are completely unreferenced. This is difficult...several sections based on one or 2 sources, so may only be one ref at end of a long para. The original article was largely unref'd, and these sections remain so. I will place cn templates to begin. The caption for TENS is not supported by the references Felt article needed more images. It doesn't really contribute greatly tbh...Reused ref for the accompanying section in the caption...to qualify "may increase the strength of the involved muscles". If you were talking about no use of term TENS in the accompanying text, this has been defined. Article should be written in prose form rather than in point form (see epidmiology section for one issue) converted most bulleted/numbered lists to prose. Remaining bullet list is the outline of surgical options (more understandable as lists?) See also section terms should be combined in to the article see also section removed, terms combined apart from National Public Toilet Map, which I don't feel was significant enough (scheme in one country...) All sources for medical information needs to meet WP:MEDRS. This one does not http://web.archive.org/web/20080626223203/http://www.continence-foundation.org.uk/publications/pdfs/Sphincter+Exercises+9.PDF nor does this one here http://www.ncbi.nlm.nih.gov/pubmed/15900425 We should be using secondary sources not primary sources http://web.archive.org/web/20080626223203/http://www.continence-foundation.org.uk/publications/pdfs/Sphincter+Exercises+9.PDF this was used in the article before I started my edits...I can't seem to access it and the website seems to have been redesigned and I can't find any downloadable pdfs. I will move www.continence-foundation.org.uk to external refs for now. http://www.ncbi.nlm.nih.gov/pubmed/15900425 removed Some references are also a little old. We should be using literature from 3-5 years and at most 10. http://www.ncbi.nlm.nih.gov/pubmed/3769707 removed This is a start. While write more once these are addressed. Doc James (talk · contribs · email) (if I write on your page reply on mine) 18:19, 14 December 2012 (UTC) Primary sources in this article By my count, there are 38/61 references that are primary. Having said that: the remaining secondary sources are cited much more frequently, and form the bulk of the article usually, primary sources are cited for statements in their background/introduction section I guess there is nothing to do but look at how each primary is used, and see if it can be replaced by a secondary or assess whether it is needed at all. lesion (talk) 19:44, 21 December 2012 (UTC) Agree. Ping me when you are finished and I will review further :-) Doc James (talk · contribs · email) (if I write on your page reply on mine) 02:17, 23 December 2012 (UTC) 11/46 are still primary... lesion (talk) 07:15, 24 December 2012 (UTC) ok, it's done lesion (talk) 21:31, 24 December 2012 (UTC) I contacted Doc James on his talk page. I think that's what "ping" means. Biosthmors (talk) 19:28, 27 December 2012 (UTC) Lead The infobox disease should be added to. Added disease DB, emdicine, medlineplus fields. Unsure if other fields can be filled for this topic. When referencing textbooks page numbers are needed. A link to google books is also very nice Added page ranges corresponding to chapters, although other sections of ASCRS texbook are cited occasionally I think. Unsure how to link to google books... We typically do not use the term "patient" per WP:MEDMOS Doc James (talk · contribs · email) (if I write on your page reply on mine) 12:04, 31 December 2012 (UTC) removed almost all instances of words patient, patients. Remaining are when directly quoting sources Classification We do not typically use bolding such as has been used. Typically use use subheadings. changed to subheadings Another thing to check is that we typically only link a term once in an article (encopresis is linked many times) corrected many instances of repeated wikilinking Differential diagnosis Would be interesting to know how often different surgeries cause FI. Doc James (talk · contribs · email) (if I write on your page reply on mine) 12:04, 31 December 2012 (UTC) added some %ges to epidemiology section Treatment Non brand names should not be capitalized can't see any more instances of this left now Would summarize the surgery section in a paragraph or two and move much of it to a subpage where it can be dealt with in more detail. See the obesity article for an example of where this was done. looked at obesity article. Management of obesity is largely conservative, whilst management of FI is more surgical? Might this affect decision to nest... In the table Pseudodiarrhea is mentioned. What is this? used dfn template and wikilinked to Pseudodiarrhea Why are drug that may exacerbate FI in the treatment rather than the "cause" "differential diag" section? Treatment may involve substituting any problematic medication. I will move the majority of this info to causes section, but I think it best to leave one sentence in treatment mentioning meds may need to be looked at Also should float the table right and the third line treatment can be simple mentioned in the text as it is the same for all rather than in the table. don't understand comment...you want table info turned to text? If one is using the best quality source one can typically just state the facts with out the need to preface with "A Cochrane systemative review" If people wish to see the source they can click the ref ok, will remove Dose source 19 support all of this "Anti-diarrheal/ constipating agents such as Loperamide (Immodium), codeine phosphate or co-phenotrope (diphenoxylate with atropine) may be used. Loperamide reduces stool weight, small bowel motility, rectoanal inhibitory reflex sensitivity and may slightly alter resting anal tone. Codeine phsophate and co-phenotrope are less commonly used because of their relatively more significant side effects. In patients who have undergone cholecystectomy (gallbladder removal), the bile acid sequestrant colestyramine may manage minor degrees of FI if this is the underlying cause or a major contributory factor. Laxatives may be used in elderly people where FI is 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 ofimpaction. Stool bulking agents e.g. psyllium seed husk, add bulk to stool, reducing symptoms of obstructed defecation. A bulking agent also absorbs water, so may be helpful in patients diarrhea. Others feel that increasing dietary fiber may worsen symptoms. A common side effect is bloating and flatulence. Evacuation aids (suppositories or enemas) e.g. glycerine or bisacodylsuppositories may be prescribed. FI patients with poor resting tone of the anal canal may not be able to retain an enema, in which case retrograde rectal irrigation may be a better option, as this equiptment utilizes inflatable catheter to prevent loss of the irrigation tip and to provide a water tight seal as the irrigation is administered. Phenylephrine gel has recently been investigated for use in FI, but it is not licensed currently. Doses of 30% - 40% phenylephrine gel may increase maximal anal canal resting pressure to the levels comparable with the normal range." And if so maybe add it behind each statement it supports. One can hid refs with <!-- --> but it helps other editors with WP:V. I went through the source again. The following points are not supported: colestyramine, and "increasing dietary fiber may worsen symptoms". I will find refs for these points and cite this section more clearly. removed dietary fiber comment, unsourced from original article. Found secondary source for cholestyramine in FI. Also more clear inline citation of this section now Loperamide should not be a cap. done Better to paraphrase than use quotes. done, except in lead where direct quotes of definitions remain The Cochrane ref does not support "This treatment may strengthen the involved muscles and may be of benefit in patients with FI" The ref states "insufficient data to allow reliable conclusions to be drawn on the effects of electrical stimulation in the management of faecal incontinence". I agree that technically "may" can be equally replaced with "may not" and thus really means nothing. But many do not interpret it that way. Doc James (talk · contribs · email) (if I write on your page reply on mine) 12:28, 31 December 2012 (UTC) problem is quoting from within the body of the paper rather than the final conclusion. Reword of caption: "This treatment may be used in FI"... I still have concerns about due weight as the evidence to support it is so poor. Doc James (talk · contribs · email) (if I write on your page reply on mine) 20:20, 3 January 2013 (UTC) Additional sections What about section on history of the disease and it treatment? And a section on society and culture which could go into greater depth about economics and stigma. Doc James (talk · contribs · email) (if I write on your page reply on mine) 12:31, 31 December 2012 (UTC) new sections included TENS I am not seeing this as properly reflecting the sources. We should also state the main conclusions first: Related to unassisted exercises are treatments that involve electrical stimulation to the anal sphincters and pelvic floor muscles. This treatment is based on the theory of electrical muscle stimulation, the elicitation of muscular contraction using electrical impulses. These impulses mimic the normal action potential (nerve conduction) delivered by the central nervous system along nerves to muscular tissues. The impulses are delivered locally via electrodes. This kind of treatment may also be termed TENS therapy (trans-cutaneous electrical nerve stimulation). The electrodes may be placed in several ways, namely intra-anal (using an anal probe), intra-vaginal (using a vaginal probe), cutaneous (electrode pads placed on the skin) or implanted (see sacral nerve stimulation). One study found intra-anal electrical stimulation to be more efficacious than intra-vaginal. Another systematic review reported that surgically implanted sacral nerve stimulation may be more effective than exercises, and that electrical stimulation or biofeedback may be more effective than exercises alone. A period of electrical stimulation delivered to the anal sphincter complex and the pelvic floor muscles has been shown to have various effects on the physiology of the muscular tissue, e.g. enhancing the speed, strength or endurance of EAS contractions. It is also suggested that there may be enhanced sensation and awareness of the anal sphincter, and thus improved ability to voluntarily contract the EAS in response to an urge to defecate. The muscle fibers may undergo transformation from fatiguable fast twitch to less fatiguable slow twitch. Capillary density may also be improved, increasing blood supply and supporting the efficiency of muscle fibre contraction. Rarely, there may be skin reactions where the electrodes are placed, but these resolve when the stimulation is stopped. A systematic review of the use of electrical stimulation in FI stated that initial observational studies were promising, but that it is not possible to draw conclusions currently until larger, well designed randomized control trials have been carried out. What do you think about the following? Details on how TENS works can be found in the subarticle on the topic. The evidence for transcutaneous electrical nerve stimulation (TENS) for FI is poor and any benefit from it is tentative. In light of the above, intra-anal electrical stimulation to be more efficacious than intra-vaginal. 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. The systematic review uses term "electrical stimulation" rather than TENS, (maybe because it's not strictly transcutaneous?). Maybe we should have some explanation to terms like "intra-vaginal" , "intra-anal"...and also to link it so it flows nicely from the exercises section...also although this review classifies sacral nerve stimulation as a type of electrical stimulation, there is more robust evidence supporting this...as it reads below, readers may conclude that there is poor evidence for sacral nerve stimulation too... 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 the us treatment in FI is limited, and any benefit from it is tentative. In light of the above, intra-anal electrical stimulation (using an anal probe as electrode) to be more efficacious than intra-vaginal (using a vaginal probe as electrode). 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. lesion (talk) 02:37, 4 January 2013 (UTC) Medications A number of things in this section are not medications and thus should be in a different section Doc James (talk · contribs · email) (if I write on your page reply on mine) 20:36, 3 January 2013 (UTC) The cochrane review includes "evacuation aids"...these might not be considered drugs (anal plugs and evacuation aids?). Suggest I can either rename section "medications"->"medical" or make new section termed "evacuation aids" and "anal plugs" I am have never seen these dfn templates but I must say I am not a fan of them. Typically it the term links to an article that is sufficient IMO to clarify matters, otherwise just remove the term and leave the lay definition if it is short. Ok A number of the external links do not comply with WP:ELNO. Typically we do not link to charities in the main article as we are international in scope and most charities are local. Typically we do not link to lists of high quality sources but use those source in the article and they than end up in the ref list. Doc James (talk · contribs · email) (if I write on your page reply on mine) 20:53, 3 January 2013 (UTC) so removed, cochrane incontinence group, national assoc for continence (National -> US only?); consensus conference (link broken); continence foundation (UK only?), ACA (UK only?)...keep NICE guidelines? In light of above advice, use new external link international in scope [1]. lesion (talk) 02:48, 4 January 2013 (UTC) Reference density A number of sentences do not have direct references after them. For example in the first section we have Symptoms of fecal incontinence can be directly or indirectly related to the lose of bowel control. A lack of control over bowel contents, tends to worsen without treatment. Symptoms that result from leakage may includepruritus ani (intense itching sensation from anus), perianal dermatitis (irritation and inflammation of the skin around the anus), and urinary tract infections. Does that file ref support all the sentences before it? And if so maybe we can add <!--<ref name="ASCRS core subjects FI" /></blockquote> --> after each one Doc James (talk · contribs · email) (if I write on your page reply on mine) 14:02, 4 January 2013 (UTC) We also have large blocks of text that are unreferenced such as This is often due to anismus (paradoxical contraction or relaxation failure of the puborectalis). 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. Other causes of incomplete evacuation include non-emptying defects like a rectocele. Whilst anismus is largely a functional disorder, organic pathologic lesions may mechanically interfere with rectal evacuation. and Conversely, relaxation of the puborectalis reduces the pull on the junction of the rectum and the anal canal, causing the anorectal angle to straighten out (increase). A squatting defecation posture is also known to increase the anorectal angle, meaning that less effort is required to defecate when in this position. This has led to the recommendation that a squatting position be used by specific groups, for example those with constipation or rectal outlet obstruction (obstructed defecation, e.g. anismus). Doc James (talk · contribs · email) (if I write on your page reply on mine) 14:22, 4 January 2013 (UTC) as per Wikipedia:What the Good article criteria are not, 'Inline citations are not decorative elements, and GA does not have any "one citation per sentence" or "one citation per paragraph" rules', however in an article that was previously contained a lot of primary source material, it might be wise to cite every sentence...I am just learning of this hide text that appears on editing window only. Specifically re first para you pasted here, it is all supported. The second I will have to look into, might have been from a primary source now deleted. Thrid is from ASCRS textbook I will double check this too. lesion (talk) 15:05, 4 January 2013 (UTC) Thanks the article is definitely improving. Doc James (talk · contribs · email) (if I write on your page reply on mine) 15:22, 4 January 2013 (UTC) I took out the last sentence of 2nd para here. Otherwise more clearly cited from sources already used. lesion (talk) 15:52, 4 January 2013 (UTC) Delay Sorry for the delay. I am currently on the road. Will finish up the review next week. One thing is we write FI a lot. As the article is about this topic it can often just be implied rather than stated much of the time. Doc James (talk · contribs · email) (if I write on your page reply on mine) 05:33, 11 January 2013 (UTC) np, I appreciate that. I removed or reworded many instances of this, there are still some in there, but it's not excessive like it was before. lesion (talk) 10:25, 11 January 2013 (UTC) A few more The table of meds that may exacerbate, while the first can be capitalized subsequent ones should not as they are generic As this is not a disease by a symptom we should use infobox symptom. A number of other aspects could also be added to the infobox like emedicine Lead should provide a bit better of the overview of the article. For example some info on epidemiology and treatment is needed. ref 10 requires a non primary source There is sort of duplication as we discuss the causes both under differential and classification by cause. Wondering if we should merge the cause section into the differential diag. There is still a number of bar references. Please use the cite templates. In the section on exercise a fair bit of the content is discussing the pathophysiology such as "The IAS is an involuntary, smooth muscle which contributes the majority of the resting tone of the anal canal (55%), whereas the EAS contributes only (30%)." and "It has also been suggested that the muscles of the pelvic floor do not operate individually". The treatment section should concentrate more on what treatments their are and how well they work. WP:IMAGE describes how to size images. Setting them to a specific px size is discouraged. Doc James (talk · contribs · email) (if I write on your page reply on mine) 10:32, 17 January 2013 (UTC) Doc James (talk · contribs · email) (if I write on your page reply on mine) 10:29, 17 January 2013 (UTC)  Done  Done Added MeSH ID. emedicine code was there all along, it just isn't showing up. this fixed now. OMIM, ICD-O both not applicable to this condition, no image available, no other fields can be populated atm...  Done added most often quoted prevalence and sent stating many treatments and can be varied according to cause.  Done Agree, merged No bar references left that i can see. Did you scroll through article fast and mistake a table or list for bar reference?  Done rm these 2 sentences, agree they were not contributing much  Done lesion (talk) 16:21, 17 January 2013 (UTC) Per WP:LEAD I would try to bring it up into 3 or 4 paragraphs and have it ordered similar to the body of the text. Doc James (talk · contribs · email) (if I write on your page reply on mine) 08:24, 21 January 2013 (UTC) From Biosthmors I notice the lead is one super long paragraph at the moment. Split up?  Done Can we take out the definitions from the lead? Perhaps put them in a subsection within the Classification section? Biosthmors (talk) 06:18, 7 January 2013 (UTC)  Done There is a list in Fecal_incontinence#Surgical. Should it be converted into WP:PROSE, and what source supports it?  Done.lesion (talk) 21:38, 21 January 2013 (UTC) In prognosis "Without medical management, the negative psychosocial sequelae may be marked, and symptoms may worsen over time." is a very general statement with those two mays. Are there not more specific statistics available? reworded with supporting refs. lesion (talk) 21:38, 21 January 2013 (UTC) Fecal_incontinence#Biofeedback should be reduced to one sentence, in my opinion. Does an article exist on biofeedback? If so, it should be linked. If not, maybe this content can be used to start it. The first four sentences seem to state the main idea that should be contained in one sentence (or maybe two) repeatedly. There is a biofeedback page, but it is very general and would need the section on use in FI expanded (just one sentence linking back to this page). If this section is a problem, the contents can be moved to the biofeedback page leaving just the cochrane RV findings. It is getting so that some of these treatment sections are short. Maybe merge into a new section called non operative? lesion (talk) 21:38, 21 January 2013 (UTC) I do think that leaving the cochrane RV findings and moving over to the biofeedback page makes sense. If the sections are getting short it is possible they could be collapsed into paragraphs with no subsections. We'll see what it looks like when we get there I guess. =) Biosthmors (talk) 18:44, 22 January 2013 (UTC)  Done In general, I think this article still needs work to be clear and concise, per 1a of WP:GACR. Wording can be improved in several places I feel. Let me look at this again...lesion (talk) 21:38, 21 January 2013 (UTC) Let me know if there's a specific section you feel needs work but you're not sure what to do with it because you've looked at it so many times. Biosthmors (talk) 18:45, 22 January 2013 (UTC) Ok... lesion (talk) 19:37, 22 January 2013 (UTC) More Encyclopedic? In differential diagnosis, there is this: Receptive anal sex may theoretically result in repeated injury to the IAS that could lead to minor FI, however very little research has been conducted on this topic. In one study, a small group of mostly HIV positive men who engaged in anoreceptive intercourse was compared to a control group of non anoreceptive men. The study reported that the anoreceptive group were more likely to complain of minor FI, and resting anal tone was reduced, but other anorectal physiological paramaters were comparable to the controls. The relevance of these findings to a possible link between anal sex and FI may have been confounded by the fact that most of the anoreceptive group had HIV, which leads to alteration in peri-rectal fat and other problems such as diarrhea. A second study again compared a group of men who engaged in anoreceptive sex with a non anoreceptive control group, and reported lowered resting anal canal tone in the former, but neither group complained of any FI, voluntary contraction was unaffected and no injuries were detected on endoanal ultrasound. The source it is cited to is PMID 20011265, from 2004. Aside from WP:MEDDATE being a concern, since it is from 2004, why say all this to essentially say not much? Biosthmors (talk) 22:21, 3 January 2013 (UTC) I guess you could call this defensive content...you just know this article will be a target for this kind of thing, so at the time I felt it warrants saying a few extra sentences just to make 100% clear the evidenced based answer on a possible link to anal sex. There were 2 primary sources originally here. The wording did not represent the findings very well either, making it sound like much more of a proven link when really there is none after reading the papers. The earlier paper is also totally flawed due to the anal sex group having HIV. I don't know, it probably will not stop someone from posting unsourced content anyway, so all could be reduced to one sentence..."It appears that there is no link between receptive anal sex and FI." It is also interesting that none of the textbooks even mention anal sex...I don't think the mainstream lit considers it a legitimate cause. One of the textbooks does list sexual assault and rectal foreign bodies as potential causes, which is sort of different anyway. lesion (talk) 02:08, 4 January 2013 (UTC) Also, 2004 is a secondary source mentioning the primary papers, which were 1993 and 1997.lesion (talk) 02:13, 4 January 2013 (UTC) How certain are we that there hasn't been a similar study since 2004? And yes, reducing down to a sentence to simply communicate the main idea seems best. Biosthmors (talk) 20:43, 4 January 2013 (UTC) Also, please add the PMC number to the {{cite journal}} template so it is more accessible. Thanks! Biosthmors (talk) 20:43, 4 January 2013 (UTC) Ran a quick pebmed search, seems not...and we could probably assume that any more recent studies would cite these in their background, and the only 2 papers citing these are review papers on general topics. Reduced section to one sent, added PMCID. lesion (talk) 02:42, 5 January 2013 (UTC) Does pelvic floor exercises work? We have this paragraph Pelvic floor exercises are exercises that aim to increase the strength of the pelvic floor muscles (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.[26] It has not been established whether pelvic floor exercises can be distinguished from anal sphincter exercises in practice by the people doing them.[26] It has also been suggested that the muscles of the pelvic floor do not operate individually,[3] significant as those exercises described for urinary incontinence (largely pubococcygeus) may also train the other muscles of the pelvic floor, and therefore be of benefit in FI (largely puborectalis). This unified pelvic floor activity is illustrated by phenomena such as involuntary passage of flatus during urination. Pelvic floor exercises are more commonly used to treat urinary incontinence,[26] for which there is a sound evidence base for effectiveness. More rarely are they used to treat degrees of FI where the term anal sphincter exercise may be used. The effect of anal sphincter exercises are variously stated as an increase in the strength, speed or endurance of voluntary contraction (EAS). A systematic review on the efficacy of anal sphincter exercises stated that there is a suggestion that sphincter exercises may have a therapeutic effect, but this is not certain. The researchers were unable to make any firm conclusions due to lack of available strong evidence.[26] I am reading it and want to know if pelvic floor exercises are useful for FI. I come to this bit after reading a bunch of sentences which say little about effectiveness "therefore be of benefit in FI " but it is unreferenced. I learn that it is good for urinary incontincece but that is not what this section should be about. I finally come to the conclusions at the end "A systematic review on the efficacy of anal sphincter exercises stated that there is a suggestion that sphincter exercises may have a therapeutic effect, but this is not certain. The researchers were unable to make any firm conclusions due to lack of available strong evidence" This should go first and most of the rest should be shortened / moved to the article on pelvic floor exercises. We also just state the facts of the best available literature. Rather than "A systematic review on the efficacy of anal sphincter exercises stated that there is a suggestion that sphincter exercises may have a therapeutic effect, but this is not certain. The researchers were unable to make any firm conclusions due to lack of available strong evidence" How about "The role of pelvic floor exercises in fecal incontinence is poorly determined. While there may be some benefit they appear less useful than implanted sacral nerve stimulators." With the Cochrane review supporting both. Doc James (talk · contribs · email) (if I write on your page reply on mine) 08:35, 21 January 2013 (UTC) Have a similar concern regarding the anal plug section. I consider it preferable to present the conclusions in the first sentence and than follow this with how it works, which ones are better, and who they work less well in. Doc James (talk · contribs · email) (if I write on your page reply on mine) 08:45, 21 January 2013 (UTC) Pelvic floor exercises and anal plug sections reworked based on these comments.lesion (talk) 14:04, 21 January 2013 (UTC) Images in the lead Would be good to move one of the images to the lead. What about the stylized diagram? Doc James (talk · contribs · email) (if I write on your page reply on mine) 08:47, 21 January 2013 (UTC) Agree would be nice to have an image for the infobox up top, but I feel neither of the images from the pathophysiology section would be appropriate... Not sure what image would be tbh. Something that encapsulates the topic generally, not normal anatomy diagrams or pictures of any particular treatment modality.lesion (talk) 13:20, 21 January 2013 (UTC) Yes neither one is great. Any other ideas? Doc James (talk · contribs · email) (if I write on your page reply on mine) 13:22, 21 January 2013 (UTC) The diagram you suggested probably needs this long caption, and is best viewed alongside the pathophsyiology text, making it unsuitable for the infobox. Possibly a picture of a spinal patient? or MS patient with caption stating how these conditions can cause FI? lesion (talk) 13:20, 21 January 2013 (UTC) Something like this http://www.filemount.com/pdf/image/large/2010/07/fecal-incontinence-p1.gif Doc James (talk · contribs · email) (if I write on your page reply on mine) 14:12, 21 January 2013 (UTC) Or creating something like this http://patienteducationcenter.org/articles/anatomy-fecal-continence/ Doc James (talk · contribs · email) (if I write on your page reply on mine) 14:13, 21 January 2013 (UTC) The first I think is Gray's, so it's already uploaded. I prefer the second image as it is relevant to FI and not just a diagram of normal anatomy. Not sure if they would release it into public domain for this purpose... lesion (talk) 14:22, 21 January 2013 (UTC) Email them and ask them. Or you could create your own or ask for help on commons. This of course is not required for GA. Doc James (talk · contribs · email) (if I write on your page reply on mine) 13:49, 26 January 2013 (UTC) contacted. lets see what they say...lesion (talk) 18:25, 26 January 2013 (UTC) History section Which refs support which line of text? Doc James (talk · contribs · email) (if I write on your page reply on mine) 08:48, 21 January 2013 (UTC) Same for the prognosis section. Does ref 5 support all the sentences in question? If so could you add <!--<ref name="NICE guidelines" /> --> This will keep people from coming and adding cn tags.Doc James (talk · contribs · email) (if I write on your page reply on mine) 08:50, 21 January 2013 (UTC) I have placed hidden citations for each sent as suggested.lesion (talk) 14:04, 21 January 2013 (UTC)