**2.4 Evaluating patients with dysfunctional anorectum and pelvic floor disorders**

In the diagnostic approach of dysfunctional anorectum and pelvic floor disorders (idiopathic incontinence, constipation of functional obstructed defecation, and perineal pain syndromes) that contribute to the history, a careful physical examination, specialized investigations, and the exclusion of anorectal or endopelvic organic disease should be carried out. In incontinent patients, the history may elicit leaking of enteric content (gases, fluid stool, or formed stool) and record the frequency, duration, severity, and timing of incontinence episodes. The incontinence may be true or false (over flow diarrhea), passive (neurogenic incontinence) or uncontrolled (diarrhea, trauma of anal sphincter, or puborectalis). However, a past medical history (obstetric, anorectal surgeries, constipation with straining at stool, rectal prolapse, low back pain, sciatica, and medications) should carefully be assessed. On physical examination should be looked for signs of incontinence. Perineal inspection (at rest and strain) may show perianal soiling, patulous anus, scars, prolapsing hemorrhoids, perineal descent, or rectal prolapse. The absence of anocutaneous reflex indicates pudendal neuropathy. Digital rectal examination may reveal tumors or impacted stool and at the same time allows the internal and external sphincter function evaluation (at rest and squeeze) as well as anorectal ring of the puborectalis assessment by palpation. Rectosigmoidoscopy should always be carried out to exclude neoplasms, proctitis, internal rectal prolapse, or a solitary rectal ulcer. At the end of the patient's interview should be determined the degree of incontinence (mild, moderate, and severe) and then some specialized tests should be recommended, if necessary. This can be done using a proposed incontinence scoring
