The history must not be focused only on AI, but rather to retrieve all patient’s medical informations concerning systemic disorders and co-morbidities as urinary incontinence, previous surgery (mainly on the posterior compartment and gynecological procedures), spinal injuries, parity, drugs, and lifestyle. Moreover, the patient should be questioned on bowel function and on bowel care including diet, fluid intake and laxatives, and how these influence AI. Then, the symptoms experienced by the patient must be investigated and pointed out just like every kind of AI or other conditions which cause soiling (e.g., fistulas, external hemorrhoids, anal, or low rectal tumors). If the patient describes an AI only for liquid stool, then a colonic cause of diarrhea should be excluded. If an AI is present, it must be differentiated as a flatus incontinence, passive leakage, or urge incontinence (Table 12.2), never forgetting that an overlapping between these conditions is always possible. Furthermore, the need of pads, duration, frequency and timing of AI’s episodes must be outlined. Hence, the severity of AI can be graduated as: (a) minor, if incontinence happens less than once a month; (b) moderate, if incontinence to solids happens more than once a month or to liquids more than once a week; (c) severe, when incontinence to solids and/or liquids happens daily or several times a week. All these characteristics can be better classified with grading systems as the Wexner score system (Table 12.3) or the American Medical Systems (AMS) score (Table 12.4), which allows to use an objective parameter to evaluate AI, to verify the response to therapy and to follow up its evolution.

Last but not least, it is of enormous relevance to question the patients, possibly with questionnaires such as the SF-36, on restrictions, quality of life, satisfaction, needs, sexual dysfunction, and on how AI influences them [1–3].

The proctological examination should start from the inspection of the perineum and anus checking their integrity and looking for scar from previous surgery or episiotomies, absence of the perineal body, a keyhole deformity of the anus suggesting a sphincter defect, or just for irritation or excoriation of the skin due to soiling. Moreover, during the inspection one should ask the patient to strain in order to check the presence of a descending perineum or of mucosal, hemorrhoidal or full-thickness rectal prolapse. Then, the digital rectal examination verifies the sphincter tone at rest (indicative of internal anal sphincter function), in contraction (indicative of external anal sphincter function) and during squeezing, the latter to check the function of the puborectalis muscle which with squeezing should push the examiner’s finger anteriorly. Asking the patient to cough will result in an external sphincter contraction, thus checking the anal sphincter reflex. The rectal examination may show an asymmetry of the sphincter suggesting a regional defect. Finally, a proctoscopy and a rectosigmoidoscopy with a rigid instrument must be done to complete the proctological visit.