and is not usually recommended as the sole intervention. Biofeedback may be of benefit in selected patients. Surgery should be considered if incontinence is due to perineal laxity or other conditions that may be reversible. Recognition of fecal impaction is also critical to addressing urinary incontinence, because the 2 conditions are often related. Education of trainees should stress diagnosis of this condition using rectal examination and plain-film radiographs to document fecal loading. A urinalysis should always be performed to assess whether a coexisting urinary infection is also present Many trials of drug therapy for fecal incontinence are of limited duration, are not randomized due to small numbers of patients studied, and are not blinded. The latter is difficult when interventions such as enemas are used. Crossover trials of longer duration have been suggested by review of the current literature.120 Rectal prolapse Rectal prolapse is particularly devastating in older patients, because it can lead to impaction, trauma, and bleeding. Early or minor prolapse often responds to treatment of constipation or impaction, because straining is a major risk factor for progression of prolapse. Unfortunately, severe prolapse is not likely to improve unless treated surgically. A recent review indicates that perineal repair or use of laparoscopic technique is better tolerated in the geriatric population than abdominal repair.129 Colorectal neoplasia Colon cancer is a common disorder in older patients, primarily because most colon cancers occur sporadically and are associated with polyp formation. The observation that crypt cell production rate is significantly higher in colonic tissue from aged rats130 raises the question of whether normal aging predisposes the colon to malignant transformation. The aged colon may be more sensitive to the oncogenic effects of growth factors and carcinogens. The active metabolite of the colonic carcinogen azoxymethane, methylazoxymethanol, induces a greater stimulation of ornithine decarboxylase activity and tyrosine kinase activity in aged rats compared with their younger counterparts.131 Similar results have been reported with transforming growth factor α and insulin-like growth factor I, both potent mitogens for a variety of tissues in the GI tract, including the colon.132, 133 It is not yet clear whether changes in the expression and/or affinity of transforming growth factor α receptors or altered postreceptor events contribute to this process. The risk of polyp formation increases significantly with age older than 50 years. Age alone should not preclude surgical intervention. A recent study of 1160 patients with colon cancer followed up from 1970 to 2000 indicated that the relative survival rate for 398 patients aged 70–95 years (70.5%) was similar to that of patients younger than 70 years (71.6%).134 A retrospective review of 88 patients older than 80 years diagnosed with colon cancer of Dukes’ B–D between 1995 and 2000 found that 61% were deemed operable, and the in-hospital mortality rate was low at 2%.135 One- and 3-year survival was 88% and 49%, respectively, which is comparable to that of younger patients with similar severity of disease. This also highlights the importance of colorectal cancer screening in those older than 80 years. The majority of patients in the study by Kirchgatterer et al were diagnosed during investigation of symptoms such as bleeding, anemia, or presence of a suspicious mass, at a time when screening methods did not routinely include full colonoscopy.