Acta Oncologica, 2015; 54: 882–888

ORIGINAL ARTICLE

Pudendal nerve injury in men with fecal incontinence after

radiotherapy for prostate cancer

ARUN LOGANATHAN1, ANN C. SCHLOITHE2, JONATHON HUTTON3, ERIC K. YEOH3,

ROBERT FRASER4, PHILLIP G. DINNING5 & DAVID WATTCHOW6
1Department of Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia, 2Department of Surgery,
Anorectal Lab, Flinders University, Adelaide, South Australia, Australia, 3Department of Radiation Oncology,
Royal Adelaide Hospital, Adelaide, South Australia, Australia, 4School of Medicine, Flinders University, Adelaide,
South Australia, Australia, 5School of Medicine, Flinders University, Adelaide, South Australia, Australia and
6Department of Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia

ABSTRACT
Background. The precise etiology of fecal incontinence (FI), which occurs frequently following external beam
radiotherapy (EBRT) for prostate carcinoma is unknown. It is possibly related to pelvic nerve injury. The aim of this
study was to assess the incidence of pudendal nerve dysfunction in men with FI after EBRT for prostate cancer compared
to men with FI but no history of EBRT.
Material and methods. Data were evaluated from 74 men with intact anal sphincters on endo-anal ultrasound
(17 post-EBRT) who had been investigated for FI at a tertiary center. Wexner incontinence scores, pudendal nerve func-
tion, anorectal manometry, and rectal sensitivity were compared between the two patient groups.
Results. Post-radiotherapy patients were older (77 ⫾ 6 vs. 62 ⫾ 17 years, p ⬍ 0.005) and had worse incontinence than
those with no history of radiotherapy (Wexner score; 13 ⫾ 3 vs. 8 ⫾ 4; p ⬍ 0.005). Bilateral pudendal nerve terminal
motor latency (PNTML) was abnormal in 87% of radiotherapy versus 22% of non-radiotherapy patients (p ⬍ 0.001)
and the significant difference persisted even after correction for age differences. Anal sphincter pressures and rectal
sensitivity for both groups were similar.
Conclusion. There is a markedly higher incidence of pudendal nerve dysfunction in men with FI after EBRT for
prostate cancer compared with men with FI from other etiologies. The increased severity of incontinence in radiotherapy
patients is not matched by alterations in either anal sphincter pressures or rectal sensitivity compared to FI in non-ERBT
patients.

Carcinoma of the prostate is a significant cause of patient quality of life, is persistent and is refractory
mortality and morbidity in men [1]. External beam to treatment [6]. Previously the incidence of anorec-
radiotherapy (EBRT) is a well established treatment tal symptoms has been largely underestimated but
modality for locally advanced prostate carcinoma recent data shows the incidence of soiling and FI
and is associated with a 50% reduction in the 10-year post-EBRT for prostate cancer to be over 50% even
prostate cancer mortality [2]. Planning and delivery three years post-radiotherapy [5].
of EBRT has evolved to improving targeting of tumor The mechanisms underlying FI after radiotherapy
irradiation while minimizing exposure to surround- for carcinoma of the prostate remain incompletely
ing organs [3] but inclusion of a part of the rectum understood, but both external anal sphincter (EAS)
and anal canal cannot be avoided in the radiation and internal anal sphincter (IAS) dysfunction are con-
field. Thus, patients frequently report anorectal sidered important [7]. In addition, decreased rectal
sequelae, such as increased stool frequency, fecal compliance, reflecting increased rectal wall stiffness
urgency, fecal incontinence (FI) and rectal bleeding and reduced rectal capacity may also have a role [8].
[4,5]. FI in particular is a significant complication of The etiology of anorectal dysfunction after
EBRT because it leads to major impairment of radiotherapy is unclear. The pelvic nerves and their

Correspondence: A. Loganathan, Pasture House, Irthington, Carlisle, CA64NN, UK. Tel: ⫹ 44 7913 308188. E-mail: a.loganathan@me.com

(Received 25 October 2014 ; accepted 17 January 2015)

ISSN 0284-186X print/ISSN 1651-226X online © 2015 Informa Healthcare
DOI: 10.3109/0284186X.2015.1010693
 Radiotherapy-induced pudendal neuropathy 883
branches, have a major role in regulation of motor,
sensory and autonomic activity in the anorectum. As
the pudendal nerve innervates the EAS and IAS,
radiation damage could contribute to the develop-
ment of FI in these patients. Pudendal nerve dys-
function has been implicated in the pathogenesis of
FI from other etiologies [9] but neural structures,
such as the pudendal nerve, which are outside the
high dose radiation field have been considered rela-
tively resistant to radiation injury. The possible con-
tribution of pudendal nerve injury to FI incontinence
post-radiotherapy has therefore received limited
attention. However, recent data reporting neural dys-
function after radiotherapy for rectal carcinoma sug-
gest that moderately high dose radiation may impact Figure 1. Flow diagram showing patient cohort selected for
directly on neural activity [10]. the study.
We therefore assessed pudendal nerve function,
along with incontinence severity, and anorectal motor nerve stimulation technique (13L40 St Mark’s
and sensory function in men with FI who had previ- Pudendal ElectrodeTM, Medtronic Functional
ously undergone EBRT. The incontinence severity, Diagnostics A ⁄ S, Skovlunde, Denmark). Square
neural and anorectal function data were compared wave stimuli of 0.05 ms duration and 10 mA were
with that of men with FI who had not undergone delivered at one-second intervals. The electromyo-
EBRT as a control group. graphy (EMG) recordings were acquired via a
MacLab or PowerLab 8S or 4S system with a
Material and methods MacLab or PowerLab bioamplifier using ScopeTM
(V3.4.3-4.1) software (ADInstruments Pty. Ltd,
Study population Castle Hill, NSW, Australia). Multiple recordings
A prospectively collected database was interrogated were taken on each side and the most well defined
to determine all patients with FI (n ⫽ 1305) who had action potentials selected for the determination of
undergone anorectal manometry at the tertiary insti- the latency. The mean latency from these multiple
tution between January 1998 and November 2013. curves was determined. Latency was defined as the
In total 114 men had been investigated for FI with time between the stimulation of the pudendal nerve
pudendal nerve terminal motor latency (PNTML) at the level of the ischial spine and commencement
testing, and anorectal manometry. Thirty-six patients of depolarization of the anal sphincter [12]. The
were excluded from the analysis due to a structural stimulus artefact (recorded electrical pulse) was
defect in the anal sphincter (n ⫽ 34) or incomplete clearly visible as evidence of correct technical func-
evaluation (n ⫽ 2) on standardized endoanal ultra- tioning of the recording technique. A lack of puden-
sound. A further four men who had radiotherapy for dal nerve response was defined as no sphincter
causes other than prostate cancer were also excluded. contraction or EMG recording in response to stim-
Of the remaining 74 men, 17 had previously under- ulus (Figure 2).
gone EBRT for prostate carcinoma while 57 had no
history of radiation treatment (Figure 1). Anorectal motility
Patients who had received radiotherapy underwent
Patient characteristics anorectal testing at a mean interval of 8.3 ⫾ 5.1
The patient age, etiology of symptoms and duration (range 3–18) years post-EBRT. Manometry was per-
of symptoms prior to testing were recorded along formed in the left lateral position, in an unprepared
with any prior history of anorectal surgery. Inconti- bowel. The water-perfused, three-channel catheter
nence severity was assessed using the Wexner incon- (external diameter 3.0 mm) (Dentsleeve Pty. Ltd,
tinence score [11]. Adelaide, Australia or Mui Scientific, Ontario,
Canada) was attached to three pressure transducers
Pudendal nerve terminal motor latency (PNTML) (Sorrenson Transpac Abbot Critical Care Systems,
IL, USA). Each channel had a side hole, and the side
PNTML assessment was performed by trained holes were arranged circumferentially, 120° to each
colorectal surgeons using a disposable glove- other and 5 mm apart. Data were recorded with a
mounted St Mark’s electrode and a transrectal MacLab or PowerLab recording system with a Maclab
884 A. Loganathan et al.

Figure 2. Normal pudendal nerve response (left panel) and absent pudendal nerve response with stimulus artifact (right panel) in a
post-radiotherapy patient.

or PowerLab bridge amplifier using ChartTM (V3.4.3- radiation oncology facilities until 2003. Two of the
V7.0.1) software (ADInstruments Pty. Ltd, Castle 3D patients also receiving radiotherapy as primary
Hill, NSW, Australia) and a MacIntoshTM computer treatment were treated to a total dose of 74 Gy in
(Apple Computer Inc., Cupertino, CA, USA). 2 Gy fractions treating 5⫻/week using a 23 MV five-
A station pull-through technique using a stan- field (anterior, APO, PAO and laterals) 3D technique
dard protocol was used with the catheter pulled with multileaf collimators to shape the fields around
through the anal canal at regular intervals with pres- the prostate target (Top right DRR, Figure 3). The
sure recordings taken at each station. The mean patient treated by salvage radiotherapy for recurrent
maximal resting (MRP) and squeeze (MSP) pres- prostate carcinoma after radical prostatectomy
sures of the three channels were determined as previ- received 3D conformal radiotherapy which first
ously described [12]. targeted the lesser pelvic lymph nodes to a dose of
Rectal capacity and time to first rectal sensation
were assessed using a low compliance balloon inserted
into the rectum. This was inflated with air to fixed
volumes for one minute then deflated (volumes of 10,
20, 40, 70, 100, 150 and 200 mls were used). The
patient reported the first sensation of the balloon, and
maximal tolerated volume. The presence of the recto-
anal inhibitory reflex (RAIR) was recorded.

Modeling of radiation dose distributions based

on available 3D CT planning scans and radiation
dose prescriptions
Of the 17 patients constituting the radiotherapy
group in this study, 16 received radiotherapy as
primary treatment for localized (T1, T2 N0 M0)
prostate carcinoma and one patient was treated by
salvage radiotherapy for recurrent disease after radi-
cal prostatectomy. The radiotherapy received by the
whole patient group between 1995 and 2010 was
delivered in 14 of the 17 patients using a 23 MV
photon four rectangular (AP/PA and laterals) field
with a two-dimensional (2D) no shielding technique
to encompass the prostate target [top left digitally Figure 3. Relationship of the pudendal nerve (in green) with the
reconstructed radiograph (DRR), Figure 3] to a total target volumes (in blue) encompassed by the digitally reconstructed
radiograph of the right lateral field corresponding to the simulated
dose of 66 Gy prescribed to the isocenter in 2 Gy
2D (top left) and simulated 3D (top right) plans and actual 3D
fractions treating 5⫻/week as 3D conformal radio- plan of the patient treated to the lesser pelvic nodes (bottom right)
therapy did not become available at the affiliated with a boost to the prostate bed (bottom left).
 Radiotherapy-induced pudendal neuropathy 885

45 Gy in 25 fractions treating 5⫻/week (Bottom right Table Ic. Effect on dose parameters of anal canal, rectum, pudendal
nerve and prostate of 3D plan using 4-field (AP/PA and laterals)
DRR, Figure 3) followed by a boost to the prostate conformal technique targeting lesser pelvic nodes to 45 Gy at
bed of 16.2 Gy in 9 fractions treating 5⫻/week isocenter in 25 fractions followed by boost to prostate bed for an
(Bottom left DRR, Figure 3) using a 23 MV photon additional 16.2 Gy at isocenter in 9 fractions treating 5x/week in
1 patient.
four-field (AP/PA and laterals) multi-collimated
technique for both target volumes. Plan 3 (n ⫽ 1) Minimum Maximum Mean SD
As the CT planning scans of the two of the three
Anal canal 2.60 58.01 39.53 17.90
3D conformal radiotherapy patients were not able Rectum (solid organ) 42.57 61.63 54.35 9.73
to be retrieved and treatment planning in the 14 Pudendal nerve 42.78 53.09 47.93 2.12
patients treated by the 2D technique was based on Prostate PTV 58.82 62.74 61.21 0.73
orthogonal (AP and lateral) treatment simulator
localization films, the treatment plans of these 16
patients were based on the CT planning data of the Statistical analysis
patient treated for recurrent prostate carcinoma Data analyzed with SPSSTM (IBM Corp. Released
after radical prostatectomy downloaded on the 3D 2010. IBM SPSS Statistics for Windows, Version
(ADAC Pinnacle) computer system. The dose vol- 19.0 Armonk, NY, USA) were compared between
ume parameters of the prostate and organs at risk the radiotherapy and non-radiotherapy groups. Due
(OARs), such as the rectum (contoured as a solid to the significant age difference between the radio-
organ), anal canal (also contoured as solid organ therapy and non-radiotherapy groups, a sub-group
from the anal verge to the anorectal junction just analysis was performed to compare data from the
below the pubo-rectalis sling around the posterior non-radiotherapy patients older than 67 (n ⫽ 27)
wall of the rectum) and pudendal nerve were with that from radiotherapy patients.
derived from the 3D planning system using the The ages, mean PNTML, MRP and MSP, rectal
prostate bed volume of the patient treated for capacity and RAIR were compared between groups
recurrent prostate carcinoma but adjusting the using ANOVA. χ2-test was used to examine differ-
dose prescriptions (as specified in paragraph above) ences between PNTML groups and Wexner inconti-
for the 14 2D patients and for the two 3D patients nence scores were compared using Mann-Whitney
with missing CT planning data (Table Ia and b). U-test. Data are mean⫾ SD. A p-value of ⬍ 0.05 was
Thus whilst the radiation dose parameters to pros- considered statistically significant in all analyses
tate target and OARs in Table Ia and b represent
simulated data, Table Ic represent the actual data
Results
of the patient treated for recurrent prostate carci-
noma after radical prostatectomy. Demographics
FI patients who had undergone EBRT were older
compared to those who had not received radiother-
Table Ia. Effect on dose parameters of anal canal, rectum, pudendal apy (Table II).
nerve and prostate of 2D plan using 4 rectangular fields (AP/PA There was no difference in the incidence of previ-
and laterals) targeting prostate to 66 Gy at isocentre in 33 fractions ous anorectal surgical procedures between the two
treating 5x/week in 14 patients.
groups (Table II).
Plan 1 (n ⫽ 14) Minimum Maximum Mean SD

Anal canal 2.49 62.31 27.53 14.88 Table II. Patient demographics and previous surgical procedures.
Rectum (solid 1.55 66.86 40.74 18.66 * p ⬍ 0.005.
organ)
Non-radiotherapy Radiotherapy
Pudendal nerve 3.34 35.77 27.14 10.32
group group
Prostate PTV 61.52 67.67 66.19 0.80
Number of patients (n) 57 17
Mean age ⫾ SD 62 ⫾ 17 77 ⫾ 6*
Table Ib. Effect on dose parameters of anal canal, rectum, pudendal Mean Wexner Incontinence 8⫾4 13 ⫾ 3*
nerve and prostate of 3D plan using 5-field conformal technique Score ⫾ SD
targeting prostate to 74 Gy at isocenter in 37 fractions treating Previous 8(14) 3(17.6)
5x/week in 2 patients.
hemorrhoidectomy (%)
Plan 2 (n ⫽ 2) Minimum Maximum Mean SD Previous fissure surgery (%) 1(1.8) 0
Previous fistula surgery (%) 2(3.5) 0
Anal canal 1.28 60.35 17.12 11.08 Previous rectal prolapse 1(1.8) 0
Rectum (solid organ) 0.77 75.41 35.96 24.07 surgery (%)
Pudendal nerve 6.94 24.39 17.04 3.3 Previous anorectal 0 1(1.8)
Prostate PTV 68.26 75.41 73.66 1.01 trauma (%)
886 A. Loganathan et al.
Symptoms the non-radiotherapy group (189.6 ⫾ 94.5 cm H20 vs.
245.8 ⫾ 74.7 cm H20, p ⬍ 0.05). However, when the
Wexner incontinence scores were recorded in 35 of the
radiotherapy group was compared to age-matched
57 men (61.4%) in the non-radiotherapy and 14 of the
non-radiotherapy patients, no differences were found
17 men (82.3%) in the radiotherapy group. Patients
between mean resting pressures (55 ⫾ 29 cm H20 vs.
who had received ERBT had more severe incontinence
63.2 ⫾ 26.3 cm H20, p ⫽ NS) or MSPs (189.6 ⫾ 94.5 cm
compared to other patients with FI (Table II). Age had
H20 vs. 223.8 ⫾ 70.1 cm H20, p ⫽ NS).
no effect on incontinence severity with the Wexner
In the 10 post-radiotherapy patients with absent
incontinence scores remaining significantly higher in
pudendal nerve responses both mean resting
the radiotherapy patients after matching for age (13 vs. 9,
pressure and MSP were below the normal range but
p ⬍ 0.05, data not shown).
were not significantly different from pressures in
post-radiotherapy patients with delayed or normal
Pudendal nerve terminal motor latency (PNTML) PNTML (Table IV).
Normal ranges for PNTML (1.4–2.6ms) have been
defined in a previous study from our unit [13]. Data Rectal capacity and recto-anal inhibitory reflex
for PNTML were available for 16/17 (94.1%) There was no difference in the volume to stimulate
patients in the radiotherapy group and 46/57 (80.7%) the recto-anal inhibitory reflex between the radio-
patients in the non-radiotherapy group. therapy and non-radiotherapy groups. There was no
There was no unilateral or bilateral pudendal significant difference in either rectal capacity (maxi-
nerve response in 10/16 radiotherapy patients mum tolerated rectal volume) or rectal sensitivity
(62.5%) compared to 3/46 (6.5%) patients in the (volume to first perception) between radiotherapy
non-radiotherapy group (p ⬍ 0.001, Table III). A fur- and the non-radiotherapy groups (Table V).
ther four patients (25.1%) in the radiotherapy group
had delayed bilateral or unilateral PNTML responses
compared to seven (15.2%) in the non-radiotherapy Actual and simulated radiation dose distributions
group (p ⬍ 0.001, Table III). Only two patients Despite the higher dose to the prostate, the mean
(12.5%) in the radiotherapy group had normal bilat- radiation doses to the OARs were lower in the patients
eral PNTML compared to 36 (78.3%) in the non- treated with 3D conformal radiotherapy compared
radiotherapy group (p ⬍ 0.001, Table III). with the 2D technique (Table Ia and b). Interest-
Matching for age, there was no unilateral or bilat- ingly, as shown in Table Ia and b, the mean dose to
eral pudendal nerve response in 10/16 EBRT patients the pudendal nerve closely parallels the mean dose
(62.5%) compared to one patient (1 of 27 older than to the anal canal and the mean anal dose for these
67 years; 3.7%) in the non-radiotherapy group 2D and 3D patients based on the modeled treatment
(p ⬍ 0.001, data not shown). plans was well below the 40 Gy suggested as a dose
constraint by Alsadius et al. [14]. In contrast, both
Anorectal manometry the suggested dose constraint for the anal canal and
the generally accepted pudendal nerve tolerance
Although mean resting pressure in the radiotherapy (mean and maximum) dose were approached based
group was within the normal range for our laboratory on the actual dose distributions of the patient treated
(54–124 cm H20) it was significantly lower compared for recurrent disease after radical prostatectomy
to non-radiotherapy patients (55 ⫾ 29 cm H20 vs. (Table Ic). This patient had FI and abnormalities of
83 ⫾ 35.4 cm H20, p ⬍ 0.05). pudendal nerve function.
Similarly the MSP in the radiotherapy group
was also within the normal range (normal range 179–
317 cm H20) but was significantly lower compared to
Table IV. MSP and MRP in the radiotherapy group subdivided
by PNTML. p ⫽ NS. * below normal range.
Table III. PNTML measurements; Normal range for PNTML is
1.4–2.6 ms. * p ⬍ 0.001. MRP⫾ SD MSP⫾ SD
(cm H20) (cm H20)
Non-radiotherapy Radiotherapy Radiotherapy group Normal range Normal range
PNTML group group (%) group (%) subdivided by PNTML n (55–124) (179–317)

Normal bilateral 36 (78.3) 2 (12.5)* Normal bilateral 2 83 ⫾ 37 265.5 ⫾ 112

Unilateral or bilateral 7 (15.2) 4 (25)* Unilateral or bilateral 4 63.3 ⫾ 22.8 214.3 ⫾ 109
delayed delayed
No PN response unilateral 3 (6.5) 10 (62.5)* No PN response unilateral 10 49.2 ⫾ 28.7* 162.6 ⫾ 89.9*
or bilateral or bilateral
 Radiotherapy-induced pudendal neuropathy 887
Table V. Recto-anal inhibitory index (RAIR), volume to first rectal sensation and maximum tolerated
rectal volume in the radiotherapy and non-radiotherapy groups. p ⫽ NS.

RAIR⫾ SD Volume to first Maximum tolerated

Patient group (mls) sensation⫾ SD (mls) volume⫾ SD (mls)

Non-radiotherapy 13.9 ⫾ 6.8 32.5 ⫾ 32.3 178.9 ⫾ 38.9

Radiotherapy 14.4 ⫾ 8.1 24.1 ⫾ 12.8 167.6 ⫾ 39.3

Discussion sphincter function and FI severity in our study.

A previous study has shown that 44% of men with FI
The study data show that men with FI following
had normal anal sphincter resting and squeeze pres-
radiotherapy for carcinoma of the prostate have a far
sures [15]. Another study demonstrated that there
higher incidence of pudendal nerve dysfunction
was no correlation between incontinence severity and
(manifest as absent or significantly delayed PNTML)
sphincter pressures in men; all incontinent males had
than men with FI from other causes. The data also
normal resting and squeeze pressures [19].
show an increased severity of FI in the post-EBRT
Previously studies after EBRT have also described
patients. While post-radiation patients had lower
abnormal sensory function, with reduced compli-
resting and squeeze pressures, these were still within ance and hypersensitivity to rectal distension in
the normal range and when compared to age matched addition to lower anal sphincter pressures [8,18,20].
non-radiotherapy patients no differences were However, we were unable to demonstrate this in the
observed. This suggests the reduction in resting and current study. These differences may be related to
squeeze pressures is likely to be an age-related phe- small sample size in the radiotherapy group and
nomenon [15,16]. There were also no differences in methodological factors. This and a previously
rectal sensation or the recto-anal inhibitory reflex reported study [18] measured sensation and compli-
between the groups. ance using an air-filled balloon in comparison to an
The major new finding in the current study is electronic barosat in another previously reported
the demonstration of severe pudendal nerve injury study [8].
in patients after radiotherapy. In fact, the majority To date the mechanisms underlying decreased
of patients in the radiotherapy group had no puden- sphincter pressures after radiotherapy remains
dal nerve response to stimulation, i.e. there was a unknown [7,17,20]. Although direct radiation-
stimulus artifact but no muscle contraction. This induced damage to the internal and EAS has been
suggests that the nerve is still intact, as a stimulus proposed as a mechanism, endo-anal ultrasound
artifact is recorded, and resting and squeeze pres- suggests the morphology of these structures is
sures though below the normal range for these maintained after EBRT [20]. While the current data
10 patients were not significantly different from the indicates pudendal nerve injury after EBRT this did
pressures in the radiotherapy sub-group with delayed not seen to significantly correlate with anorectal
or normal PNTML. However, as the EMG cannot dysfunction. The reasons for this discrepancy are
be recorded together with the attenuation of both unclear.
the resulting resting and squeeze pressures indicates The level at which the pudendal nerve injury
a significant impairment of neural function. Acute might occur is also not evident from the current
pudendal nerve injury after radiotherapy has been study as the nerve could be damaged anywhere along
reported after combined chemo-radiotherapy for rectal its path including the neuro-muscular terminals. The
carcinoma where the bowel wall is directly targeted. course of the pudendal nerve lies outside the targeted
In this study, PNTML tested before and four weeks field of radiation [top and bottom left and top right
after completion of chemo-radiation treatment DRRs, Figure 3] except for the patient who received
showed a significant increase in the number of 45 Gy in 25 fractions treating 5⫻/week to the lesser
patients with delayed PNTML associated with new pelvis nodes (bottom right DRR, Figure 3) as part
onset incontinence and reduction in maximal treatment of local recurrence after radical prostatec-
squeeze but not resting sphincter pressures [10]. tomy. This dose fractionation is the same as the study
However, this has not been previously been demon- reporting delayed PNTL after chemoradiation for
strated after radiotherapy for prostate cancer. rectal carcinoma [15] and approaches radiation
Earlier studies have shown both acute and chronic tolerance for peripheral nerves.
compromise of anorectal function after EBRT The process of defecation is complex and involves
[17,18]. In this study we were unable to show a sig- both anorectal and colonic mechanisms. The involve-
nificant effect of EBRT on anal sphincter pressures. ment of sigmoid colon motility patterns in the main-
Thus there appears little correlation between anal tenance of continence has been recently reported
888 A. Loganathan et al.
[21] and colonic dysmotility has been implicated in [8] Krol R, Hopman WP, Smeenk RJ, Van Lin EN. Increased
the pathogenesis of incontinence after EBRT [22]. It rectal wall stiffness after prostate radiotherapy: Relation
with fecal urgency. Neurogastroenterol Motil 2012;24:
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There are several limitations in this study. The Costa M, Wattchow D. Prolonged pudendal nerve terminal
small sample size may have contributed to the motor latency is associated with decreased resting and
lack of difference in sensation between the groups. squeeze pressures in the intact anal sphincter. Colorectal Dis
2013;15:1410–5.
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focus of the study was to assess the PNTML in these erative chemoradiation for rectal cancer causes prolonged
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Declaration of interest: The authors report no sphincter region and fecal leakage among irradiated prostate
conflicts of interest. The authors alone are respon- cancer survivors. Int J Radiat Oncol Biol Phys 2012;84:
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