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Biofeedback versus bilateral transcutaneous posterior tibial nerve stimulation in the treatment of functional non-retentive fecal incontinence in children: A randomized controlled trial. J Pediatr Surg 2021; 56:1349-1355. [PMID: 33092813 DOI: 10.1016/j.jpedsurg.2020.09.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/17/2020] [Accepted: 09/18/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND Biofeedback and transcutaneous posterior tibial nerve stimulation (TPTNS) can be used in treatment of Functional non-retentive fecal incontinence (FNRFI). Aim of this study was to evaluate the early effect of Biofeedback versus (TPTNS) and treatment by Kegal exercises and dietetic regulations in management of (FNRFI) in children. METHODOLOGY The current prospective randomized controlled study included 93 children with FNRFI who were randomly allocated into the 3 groups. Group A (n = 28) were treated by dietetic regulation and Kegal exercises. Group B (n = 34) received biofeedback while group C (n = 31) received (TPTNS) for 3 months. Follow up using St' Mark's incontinence score and high resolution manometry was done at 3 and 6 months and compared to the initial records. RESULTS There was statistically significant decrease in the incontinence score in Group B and C compared to Group A at 3 and 6 months (p ˂ 0.001). Resting and squeeze pressures showed significant increase group B and C (p ˂ 0.001). Patients in Group B and C showed significant decrease volume of balloon required for 1st sensation (p ˂ 0.001 and 0.034) respectively. CONCLUSION Biofeedback is more effective than TPTNS, Kegal exercises and dietetic regulations in treatment of FNRFI in children for short term follow-up. LEVEL OF EVIDENCE Level I. TYPE OF STUDY Treatment Study.
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Sacral neuromodulation versus onabotulinumtoxinA for refractory urgency urinary incontinence: impact on fecal incontinence symptoms and sexual function. Am J Obstet Gynecol 2019; 221:513.e1-513.e15. [PMID: 31211964 DOI: 10.1016/j.ajog.2019.06.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 05/17/2019] [Accepted: 06/10/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Women with refractory urgency urinary incontinence can be treated with onabotulinumtoxinA or sacral neuromodulation. Little data exists on the comparative effects of treatment of refractory urgency urinary incontinence on other pelvic floor complaints, such as bowel and sexual function. OBJECTIVE The objective of this study was to compare the impact of these treatments on fecal incontinence and sexual symptoms. METHODS This was a planned supplemental analysis of a randomized trial in women with refractory urgency urinary incontinence treated with onabotulinumtoxinA (n = 190) or sacral neuromodulation (n = 174). Fecal incontinence and sexual symptoms were assessed at baseline and at 6, 12, and 24 months. Fecal incontinence symptoms were measured using the St Mark's (Vaizey) Fecal Incontinence severity scale. Sexual symptoms were measured using the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 (PISQ-12) and the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR). The PISQ-IR allows measurement of sexual symptoms in both sexually active and non-sexually active adults. Primary outcomes were change in Vaizey and PISQ-12 scores between baseline and 6 months. Secondary outcomes were change in PISQ-IR total and subscores between baseline and 6 months and change in Vaizey, PISQ-12, and PISQ-IR scores between baseline and 12 and 24 months. Intent-to-treat analysis was performed using repeated measures mixed model to estimate change in all parameters from baseline while adjusting for the baseline score. A subgroup analysis of women with clinically significant bowel symptoms was conducted based on baseline Vaizey score of ≥12. RESULTS At baseline, mean Vaizey scores were indicative of mild fecal incontinence symptoms and were not different between onabotulinumtoxinA and sacral neuromodulation groups (7.6 ± 5.3 vs 6.6 ± 4.9, P = .07). The proportion of sexually active women (56% vs 63%, P = .25), mean PISQ-12 score (33.4 ± 7.5 vs 32.7 ± 6.7, P = .55), or PISQ-IR subscores were also not different between the onabotulinumtoxinA and sacral neuromodulation groups at baseline. There was no difference between women treated with onabotulinumtoxinA and those treated with sacral neuromodulation at 6 months in terms of improvement in fecal incontinence symptom score (Vaizey: -1.9, 95% confidence interval -2.6 to -1.2 vs -0.9, 95% confidence interval -1.7 to -0.2, P = .07) or sexual symptoms score (PISQ-12: 2.2, 95% confidence interval 0.7 to 3.7 vs 2.2, 95% confidence interval 0.7 to 3.7, P = .99). There was no difference in improvement between groups in the sexual symptom subscores in sexually active and non-sexually active women at 6 months. Similar findings were noted at 12 and 24 months. In a subgroup (onabotulinumtoxinA = 33 and sacral neuromodulation = 22) with clinically significant fecal incontinence at baseline (Vaizey score ≥12), there was a clinically meaningful improvement in symptoms in both groups from baseline to 6 months, with no difference in improvement between the onabotulinumtoxinA and sacral neuromodulation groups (-5.1, 95% confidence interval -7.3 to -2.8 vs -5.6, 95% confidence interval -8.5 to -2.6, P = .8). CONCLUSION There were no differences in improvement of fecal incontinence and sexual symptoms in women with urgency urinary incontinence treated with onabotulinumtoxinA or sacral neuromodulation. Women with significant fecal incontinence symptoms at baseline had clinically important improvement in symptoms, with no difference between the treatments. Our findings can help clinicians counseling women considering treatment for refractory urgency urinary incontinence.
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Sarveazad A, Babahajian A, Amini N, Shamseddin J, Yousefifard M. Posterior Tibial Nerve Stimulation in Fecal Incontinence: A Systematic Review and Meta-Analysis. Basic Clin Neurosci 2019; 10:419-431. [PMID: 32284831 PMCID: PMC7149953 DOI: 10.32598/bcn.9.10.290] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 05/15/2018] [Accepted: 09/28/2018] [Indexed: 12/14/2022] Open
Abstract
Introduction: The present systematic review and meta-analysis aims to investigate the role of Posterior Tibial Nerve Stimulation (PTNS) in the control of Fecal Incontinence (FI). Methods: Two independent reviewers extensively searched in the electronic databases of Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, CINAHL, and Scopus for the studies published until the end of 2016. Only randomized clinical trials were included. The studied outcomes included FI episodes, FI score, resting pressure, squeezing pressure, and maximum tolerable pressure. The data were reported as Standardized Mean Differences (SMD) with 95% confidence interval. Results: Five articles were included in the present study (249 patients under treatment with PTNS and 239 in the sham group). Analyses showed that PTNS led to a significant decrease in the number of FI episodes (SMD=−0.38; 95% CI: −0.67–0.10; P=0.009). Yet, it did not have an effect on FI score (SMD=0.13; 95% CI: −0.49–0.75; P=0.68), resting pressure (SMD=0.12; 95% CI: −0.14–0.37; P=0.67), squeezing pressure (SMD=−0.27; 95% CI: −1.03–0.50; P=0.50), and maximum tolerable pressure (SMD=−0.10; 95% CI: −0.40–0.24; P=0.52). Conclusion: Based on the results, it seems that the prescription of PTNS alone cannot significantly improve FI.
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Affiliation(s)
- Arash Sarveazad
- Colorectal Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Asrin Babahajian
- Liver and Digestive Research Center, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Naser Amini
- Cellular and Molecular Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Jebreil Shamseddin
- Molecular Medicine Research Center, Hormozgan Health Institute, Department of Parasitology, Faculty of Medicine, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Mahmoud Yousefifard
- Physiology Research Center, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
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de Sousa HA, da Silva MDG, Barbosa KDP, Vianna LMDS, Pacheco YG, de Godoy JRP, Kuckelhaus SAS. Electrical stimulation structurally affects the tissues of the rectum and anus of nulliparous rats. J Anat 2017; 231:398-404. [PMID: 28547814 PMCID: PMC5554829 DOI: 10.1111/joa.12635] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2017] [Indexed: 12/20/2022] Open
Abstract
Considering that the muscles of the anus perform a critical role in maintaining continence, losses in their structure can negatively affect the physiological control of the intestinal contents. Anorectal electro-stimulation (ARES) has been reported to have a positive effect on the functionality of treated patients, but how ARES affects the structural tissues of the anorectal segment remains unknown. Because the study of how ARES structurally affects human tissues is not possible, this study aimed to clarify these effects in a murine model, which has a similar anorectal segment (structure and physiology) to humans. For the descriptive and comparative study, randomly selected nulliparous adult Wistar rats (n = 5) were submitted to 30 anorectal sessions of ARES with a biphasic current (700 μs, 50 Hz from 2 to 4 mA). After treatment, the animals were euthanized, and the anorectal segments were dissected and processed for histopathological analysis. Our results showed that ARES increased the widths of the mucosal, submucosal and muscle layers of the rectum, as well as the number of leukocytes in the mucosa. ARES also caused hyperplasia of the smooth muscle of the internal anal sphincter and hypertrophy of the external anal sphincter muscle. In conclusion, our results showed that ARES had not only a positive effect on the structure (morphology) of all tissues associated with the rectum and anus but, more importantly, on the structural gain of the muscles (hyperplasia and hypertrophy), which could point to a functional gain of the anal sphincter, reinforcing the applicability of ARES as a non-invasive treatment for anal incontinence.
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Affiliation(s)
- Hugo Alves de Sousa
- Laboratory of Molecular Anatomy and NanomedicineArea of MorphologyFaculty of MedicineUniversity of BrasiliaBrasiliaFederal DistrictBrazil
| | - Maria da Glória da Silva
- Laboratory of HistologyArea of MorphologyFaculty of MedicineUniversity of BrasiliaBrasiliaFederal DistrictBrazil
| | | | | | - Yolanda Galindo Pacheco
- Laboratory of Molecular Anatomy and NanomedicineArea of MorphologyFaculty of MedicineUniversity of BrasiliaBrasiliaFederal DistrictBrazil
| | - José Roberto Pimenta de Godoy
- Laboratory of Molecular Anatomy and NanomedicineArea of MorphologyFaculty of MedicineUniversity of BrasiliaBrasiliaFederal DistrictBrazil
| | - Selma Aparecida Souza Kuckelhaus
- Laboratory of Molecular Anatomy and NanomedicineArea of MorphologyFaculty of MedicineUniversity of BrasiliaBrasiliaFederal DistrictBrazil
- Laboratory of Cell ImmunologyArea of PathologyFaculty of MedicineUniversity of BrasiliaBrasiliaFederal DistrictBrazil
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Ussing A, Dahn I, Due U, Sørensen M, Petersen J, Bandholm T. Supervised pelvic floor muscle training versus attention-control massage treatment in patients with faecal incontinence: Statistical analysis plan for a randomised controlled trial. Contemp Clin Trials Commun 2017; 8:192-202. [PMID: 29696209 PMCID: PMC5898528 DOI: 10.1016/j.conctc.2017.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 07/12/2017] [Accepted: 07/20/2017] [Indexed: 02/06/2023] Open
Abstract
Introduction Faecal incontinence affects approximately 8–9% of the adult population. The condition is surrounded by taboo; it can have a devastating impact on quality of life and lead to major limitations in daily life. Pelvic floor muscle training in combination with information and fibre supplements is recommended as first-line treatment for faecal incontinence. Despite this, the effect of pelvic floor muscle training for faecal incontinence is unclear. No previous trials have investigated the efficacy of supervised pelvic floor muscle training in combination with conservative treatment and compared this to an attention-control massage treatment including conservative treatment. The aim of this trial is to investigate if 16 weeks of supervised pelvic floor muscle training in combination with conservative treatment is superior to attention-control massage treatment and conservative treatment in patients with faecal incontinence. Design Randomised, controlled, superiority trial with two parallel arms. Methods 100 participants with faecal incontinence will be randomised to either (1) individually supervised pelvic floor muscle training and conservative treatment or (2) attention-control massage treatment and conservative treatment. The primary outcome is participants' rating of symptom changes after 16 weeks of treatment using the Patient Global Impression of Improvement Scale. Secondary outcomes are the Vaizey Incontinence Score, the Fecal Incontinence Severity Index, the Fecal Incontinence Quality of Life Scale, a 14-day bowel diary, anorectal manometry and rectal capacity measurements. Follow-up assessment at 36 months will be conducted. Discussion This paper describes and discusses the rationale, the methods and in particular the statistical analysis plan of this trial.
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Affiliation(s)
- Anja Ussing
- Department of Physiotherapy-and Occupational Therapy, Copenhagen University Hospital, Hvidovre, Kettegaards Allé 30, DK-2650 Hvidovre, Denmark.,Optimed, Clinical Research Center, Copenhagen University Hospital, Hvidovre, Kettegaards Allé 30, DK-2650 Hvidovre, Denmark
| | - Inge Dahn
- Department of Surgical and Medical Gastroenterology, Copenhagen University Hospital, Hvidovre, Kettegaards Allé 30, DK-2650 Hvidovre, Denmark
| | - Ulla Due
- Department of Obstetrics and Gynaecology, Herlev Hospital, Herlev Ringvej 75, DK-2730 Herlev, Denmark.,Department of Occupational and Physical Therapy, Herlev Hospital, Herlev Ringvej 75, DK-2730 Herlev, Denmark
| | - Michael Sørensen
- Department of Surgical and Medical Gastroenterology, Copenhagen University Hospital, Hvidovre, Kettegaards Allé 30, DK-2650 Hvidovre, Denmark
| | - Janne Petersen
- Optimed, Clinical Research Center, Copenhagen University Hospital, Hvidovre, Kettegaards Allé 30, DK-2650 Hvidovre, Denmark
| | - Thomas Bandholm
- Department of Physiotherapy-and Occupational Therapy, Copenhagen University Hospital, Hvidovre, Kettegaards Allé 30, DK-2650 Hvidovre, Denmark.,Optimed, Clinical Research Center, Copenhagen University Hospital, Hvidovre, Kettegaards Allé 30, DK-2650 Hvidovre, Denmark.,Physical Medicine & Rehabilitation Research - Copenhagen (PMR-C), Copenhagen University Hospital, Hvidovre, Kettegaards Allé 30, DK-2650 Hvidovre, Denmark
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Vigorita V, Rausei S, Troncoso Pereira P, Trostchansky I, Ruano Poblador A, Moncada Iribarren E, Facal Alvarez C, de San Ildefonso Pereira A, Casal Núñez E. A pilot study assessing the efficacy of posterior tibial nerve stimulation in the treatment of low anterior resection syndrome. Tech Coloproctol 2017; 21:287-293. [PMID: 28439675 DOI: 10.1007/s10151-017-1608-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Accepted: 03/02/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Low anterior resection for rectal cancer often results in severe bowel dysfunction, specifically low anterior resection syndrome (LARS), with symptoms such as incontinence, urgency, and frequent bowel movements. Percutaneous tibial nerve stimulation (PTNS) resulted in a high rate of success in patients with fecal incontinence. The aim of this study was to evaluate the effectiveness of treatment with PTNS in LARS and to identify predictors of the outcome of the technique. METHODS The study was conducted from May 2012 to April 2015 at the Alvaro Cunqueiro Hospital, University Hospital Complex of Vigo, Spain. Ten patients with LARS were recruited consecutively. All patients underwent 2 sessions per week (30 min each one) for 6 weeks. Patients were followed for 3 weeks, and those who had a significant clinical improvement were recruited to a second phase of PTNS. Some patients presenting with relapse during follow-up underwent an additional phase of PTNS. Outcome measures included Wexner scores, quality of life scores, and urgency of defecation. RESULTS Three patients did not complete the treatment due to poor response in the first phase. Incontinence was reduced in the remaining seven of ten patients. The median Wexner score at initial patient evaluation was 14 (IQR 10.75-18.5), which decreased to 10 (IQR 6.5-18) after treatment (p = 0.034). A statistically significant improvement was demonstrated in quality of life scale, lifestyle, depression, and daily defecation urgency (p < 0.05). LARS Score improvement was observed in five patients (50%) with a total resolution of LARS in 2 (20%). CONCLUSIONS PTNS is an ambulatory treatment that could play an important role in the context of a multimodal treatment approach in patients with LARS. It could be a first-line treatment to identify non-responders to conservative management who need different and more invasive treatments.
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Affiliation(s)
- V Vigorita
- Division of Coloproctology, Department of General and Digestive Surgery, University Hospital Complex of Vigo - Alvaro Cunqueiro Hospital, Estrada Clara Campoamor, 341, 36312, Vigo (Beade), Pontevedra, Spain.
| | - S Rausei
- Department of Surgery, University of Insubria, Varese, Italy
| | - P Troncoso Pereira
- Division of Coloproctology, Department of General and Digestive Surgery, University Hospital Complex of Vigo - Alvaro Cunqueiro Hospital, Estrada Clara Campoamor, 341, 36312, Vigo (Beade), Pontevedra, Spain
| | - I Trostchansky
- Division of Coloproctology, Department of General and Digestive Surgery, University Hospital Complex of Vigo - Alvaro Cunqueiro Hospital, Estrada Clara Campoamor, 341, 36312, Vigo (Beade), Pontevedra, Spain
| | - A Ruano Poblador
- Division of Coloproctology, Department of General and Digestive Surgery, University Hospital Complex of Vigo - Alvaro Cunqueiro Hospital, Estrada Clara Campoamor, 341, 36312, Vigo (Beade), Pontevedra, Spain
| | - E Moncada Iribarren
- Division of Coloproctology, Department of General and Digestive Surgery, University Hospital Complex of Vigo - Alvaro Cunqueiro Hospital, Estrada Clara Campoamor, 341, 36312, Vigo (Beade), Pontevedra, Spain
| | - C Facal Alvarez
- Division of Coloproctology, Department of General and Digestive Surgery, University Hospital Complex of Vigo - Alvaro Cunqueiro Hospital, Estrada Clara Campoamor, 341, 36312, Vigo (Beade), Pontevedra, Spain
| | - A de San Ildefonso Pereira
- Division of Coloproctology, Department of General and Digestive Surgery, University Hospital Complex of Vigo - Alvaro Cunqueiro Hospital, Estrada Clara Campoamor, 341, 36312, Vigo (Beade), Pontevedra, Spain
| | - E Casal Núñez
- Division of Coloproctology, Department of General and Digestive Surgery, University Hospital Complex of Vigo - Alvaro Cunqueiro Hospital, Estrada Clara Campoamor, 341, 36312, Vigo (Beade), Pontevedra, Spain
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Bielefeldt K. Adverse events of sacral neuromodulation for fecal incontinence reported to the federal drug administration. World J Gastrointest Pharmacol Ther 2016; 7:294-305. [PMID: 27158546 PMCID: PMC4848253 DOI: 10.4292/wjgpt.v7.i2.294] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Revised: 02/23/2016] [Accepted: 03/16/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the nature and severity of AE related to sacral neurostimulation (SNS).
METHODS: Based on Pubmed and Embase searches, we identified published trials and case series of SNS for fecal incontinence (FI) and extracted data on adverse events, requiring an active intervention. Those problems were operationally defined as infection, device removal explant or need for lead and/or generator replacement. In addition, we analyzed the Manufacturer and User Device Experience registry of the Federal Drug Administration for the months of August - October of 2015. Events were included if the report specifically mentioned gastrointestinal (GI), bowel and FI as indication and if the narrative did not focus on bladder symptoms. The classification, reporter, the date of the recorded complaint, time between initial implant and report, the type of AE, steps taken and outcome were extracted from the report. In cases of device removal or replacement, we looked for confirmatory comments by healthcare providers or the manufacturer.
RESULTS: Published studies reported adverse events and reoperation rates for 1954 patients, followed for 27 (1-117) mo. Reoperation rates were 18.6% (14.2-23.9) with device explants accounting for 10.0% (7.8-12.7) of secondary surgeries; rates of device replacement or explant or pocket site and electrode revisions increased with longer follow up. During the period examined, the FDA received 1684 reports of AE related to SNS with FI or GI listed as indication. A total of 652 reports met the inclusion criteria, with 52.7% specifically listing FI. Lack or loss of benefit (48.9%), pain or dysesthesia (27.8%) and complication at the generator implantation site (8.7%) were most commonly listed. Complaints led to secondary surgeries in 29.7% of the AE. Reoperations were performed to explant (38.2%) or replace (46.5%) the device or a lead, or revise the generator pocket (14.6%). Conservative management changes mostly involved changes in stimulation parameters (44.5%), which successfully addressed concerns in 35.2% of cases that included information about treatment results.
CONCLUSION: With reoperation rates around 20%, physicians need to fully disclose the high likelihood of complications and secondary interventions and exhaust non-invasive treatments, including transcutaneous stimulation paradigms.
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Fecal Incontinence: Etiology, Diagnosis, and Management. J Gastrointest Surg 2015; 19:1910-21. [PMID: 26268955 DOI: 10.1007/s11605-015-2905-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 07/27/2015] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Fecal incontinence is a debilitating condition affecting primarily the elderly. Many patients suffer in silence resulting in both underdiagnosis and undertreatment often culminating in an overall poor quality of life. METHODS We sought to review the etiology, diagnosis, and treatment of fecal incontinence based on current literature. Additionally, newer treatment methods such as Solesta will be evaluated. RESULTS There are many diagnostic modalities available to assess the degree and severity of the patient's incontinence; however, a thorough history and physical exam is critical. Initial attempts at treatment focus on medical management primarily through stool texture modification with the aid of bulking agents. Failure of medical therapy is often followed by a graded increase in the complexity and invasiveness of the available treatment options. The selection of the most appropriate surgical option, such as overlapping sphincteroplasty and neuromodulation, is multifactorial involving both surgeon and patient-related factors. Neuromodulation has received increased attention in the last decade due to its documented therapeutic success, and newer office-based procedures, such as the Solesta injection, are showing promising results in properly selected patients. Finally, diversion remains an option for select patients who have failed all other therapies. CONCLUSION The etiology of fecal incontinence is multifactorial, involving a complex interplay between stool consistency and anatomic integrity. The diagnosis and treatment of fecal incontinence continue to evolve and are showing promising results.
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Kim JK, Jeon BG, Song YS, Seo MS, Kwon YH, Park JW, Ryoo SB, Jeong SY, Park KJ. Biofeedback Therapy Before Ileostomy Closure in Patients Undergoing Sphincter-Saving Surgery for Rectal Cancer: A Pilot Study. Ann Coloproctol 2015; 31:138-43. [PMID: 26361615 PMCID: PMC4564665 DOI: 10.3393/ac.2015.31.4.138] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 07/08/2015] [Indexed: 02/06/2023] Open
Abstract
Purpose This study prospectively investigated the effects of biofeedback therapy on objective anorectal function and subjective bowel function in patients after sphincter-saving surgery for rectal cancer. Methods Sixteen patients who underwent an ileostomy were randomized into two groups, one receiving conservative management with the Kegel maneuver and the other receiving active biofeedback before ileostomy closure. Among them, 12 patients (mean age, 57.5 years; range, 38 to 69 years; 6 patients in each group) completed the study. Conservative management included lifestyle modifications, Kegel exercises, and medication. Patients were evaluated at baseline and at 1, 3, 6, and 12 months after ileostomy closure by using anal manometry, modified Wexner Incontinence Scores (WISs), and fecal incontinence quality of life (FI-QoL) scores. Results Before the ileostomy closure, the groups did not differ in baseline clinical characteristics or resting manometric parameters. After 12 months of follow-up, the biofeedback group demonstrated a statistically significant improvement in the mean maximum squeezing pressure (from 146.3 to 178.9, P = 0.002). However, no beneficial effect on the WIS was noted for biofeedback compared to conservative management alone. Overall, the FI-QoL scores were increased significantly in both groups after ileostomy closure (P = 0.006), but did not differ significantly between the two groups. Conclusion Although the biofeedback therapy group demonstrated a statistically significant improvement in the maximum squeezing pressure, significant improvements in the WISs and the FI-QoL scores over time were noted in both groups. The study was terminated early because no therapeutic benefit of biofeedback had been demonstrated.
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Affiliation(s)
- Jeong-Ki Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Byeong Geon Jeon
- Daejin Medical Center Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Yoon Suk Song
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Mi Sun Seo
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Yoon-Hye Kwon
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Ji Won Park
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea. ; Daejin Medical Center Bundang Jesaeng General Hospital, Seongnam, Korea. ; Cancer Research Institute, Seoul National University, Seoul, Korea
| | - Seung-Bum Ryoo
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Seung-Yong Jeong
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea. ; Cancer Research Institute, Seoul National University, Seoul, Korea. ; Colorectal Cancer Center, Seoul National University Cancer Hospital, Seoul, Korea
| | - Kyu Joo Park
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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Abstract
OBJECTIVE To develop a framework that describes the most important symptom outcomes for anal incontinence treatment from the patient perspective. METHODS A conceptual framework was developed by the Pelvic Floor Disorders Network based on four semistructured focus groups and confirmed in two sets of 10 cognitive interviews including women with anal incontinence. We explored: 1) patient-preferred terminology for describing anal incontinence symptoms; 2) patient definitions of treatment "success"; 3) importance of symptoms and outcomes in the framework; and 4) conceptual gaps (defined as outcomes not previously identified as important). Sessions were conducted according to grounded theory transcribed, coded, and qualitatively and quantitatively analyzed to identify relevant themes. Content and face validity of the framework were further assessed using cognitive interviews. RESULTS Thirty-four women participated in focus groups and 20 in cognitive interviews. Overall, 29 (54%) were aged 60 years or older, 42 (78%) were white, and 10 (19%) had a high school degree or less. Two overarching outcome themes were identified: "primary bowel leakage symptoms" and "ancillary bowel symptoms." Subdomains important in primary bowel leakage symptoms included leakage characteristics (symptom frequency, amount of leakage, symptom bother) and conditions when bowel leakage occurs (predictability, awareness, urgency). Subdomains important under ancillary bowel symptoms included emptying disorders (constipation, obstructed defecation, and wiping issues) and discomfort (pain, burning). New outcomes identified included predictability, awareness, wiping issues, and discomfort. CONCLUSION Women with anal incontinence desire a wide range of symptom outcomes after treatment. These are captured in our conceptual framework, which can aid clinicians and researchers in assessing anal incontinence. LEVEL OF EVIEDENCE: II.
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Cohen-Zubary N, Gingold-Belfer R, Lambort I, Wasserberg N, Krissi H, Levy S, Niv Y, Dickman R. Home electrical stimulation for women with fecal incontinence: a preliminary randomized controlled trial. Int J Colorectal Dis 2015; 30:521-8. [PMID: 25619464 DOI: 10.1007/s00384-015-2128-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE The purpose of this study is to compare the effectiveness and cost of home electrical stimulation and standardized biofeedback training in females with fecal incontinence METHODS Thirty-six females suffering from fecal incontinence were randomized into two groups, matched for mean age (67.45 ± 7.2 years), mean body mass index (kg/m2) (26.2 ± 3.9), mean disease duration (4.1 ± 0.8 years), mean number of births (2.7 ± 1.3), and reports of obstetric trauma (25%). Questionnaires were used to evaluate their demographics, medical, and childbearing history. Subjects were randomized to home electrical stimulation or standardized biofeedback training for a period of 6 weeks. Subjective outcome measures included the frequency of fecal, urine, and gas incontinence by visual analog scale, Vaizey incontinence score, and subjects' levels of fecal incontinence related anxiety. Objective outcome measures included pelvic floor muscle strength assessed by surface electromyography. We also compared the cost of each treatment modality. RESULTS Only females who received home electrical stimulation (HES) reported a significant improvement in Vaizey incontinence score (p = 0.001), anxiety (p = 0.046), and in frequency of leaked solid stool (p = 0.013). A significant improvement in pelvic floor muscle strength was achieved by both groups. HES was much cheaper compared to the cost of standardized biofeedback training (SBT) (US $100 vs. US $220, respectively). Our study comprised a small female population, and the study endpoints did not include objective measures of anorectal function test, such as anorectal manometry, before and after treatment. CONCLUSIONS Home electrical stimulation may offer an alternative to standardized biofeedback training as it is effective and generally well-tolerated therapy for females with fecal incontinence.
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Long-term outcome after overlapping anterior anal sphincter repair for fecal incontinence. Int J Colorectal Dis 2014; 29:1377-83. [PMID: 25185844 DOI: 10.1007/s00384-014-2005-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/22/2014] [Indexed: 02/04/2023]
Abstract
PURPOSE The aim was to assess long-term results and quality of life following anterior anal sphincter repair for anal incontinence. PATIENTS AND METHODS Twenty-three female patients underwent anterior anal sphincteroplasty over a 10-year period between January 1999 and January 2009 in a gynecological surgery department. Patients were asked to complete pre- and postoperative questionnaires comprising the Jorge and Wexner incontinence score. The secondary objective was to assess pre- and post-sphincteroplasty symptom severity and sexual quality of life. Mean follow-up was 87 months (median, 91.5 months). Kaplan-Meier time-to-event analysis was applied. RESULTS Mean age was 52 years (±15.2), and mean postoperative Jorge and Wexner score, 7.5/20 (±4.1). Seventeen patients (85 %) declared themselves satisfied by the repair; 12 (60 %) showed good fecal continence. Fecal incontinence had a negative impact on quality of life for 15 % and on sexuality for 50 % of patients. Kaplan-Meier analysis showed 85 % conservation of anal continence correction at 1 year, 74 % at 48 months, 67 % at 60 months, and 48 % at 84 months. CONCLUSIONS Overlapping anterior anal sphincter repair provided lasting improvement in fecal incontinence, with satisfactory long-term functional results. At 84 months' follow-up, 48 % of patients maintained good fecal continence, with a satisfaction rate of 85 %. Anal sphincteroplasty may be a first-line attitude in young female fecal incontinence patients with a recent sphincter defect following initially undiagnosed obstetric trauma and also restores perineal comfort.
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Abstract
Fecal incontinence (FI) is a devastating condition affecting a substantial portion of the population. The etiologies of FI are wide ranging, as are the treatment options. When conservative measures fail, often surgical intervention is required. As in any area where a wide range of treatment options exist, there is no one perfect solution. Fortunately, novel treatment options for FI are becoming available, namely, posterior tibial nerve stimulation, magnetic anal sphincter, stem cell transplant, pyloric transplantation, and acupuncture.
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Affiliation(s)
- Adam Barker
- Department of Colon and Rectal Surgery, Presbyterian Hospital, Dallas, Texas
| | - Jefferson Hurley
- Department of Colon and Rectal Surgery, Presbyterian Hospital, Dallas, Texas
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Lee YY, Erdogan A, Rao SSC. High resolution and high definition anorectal manometry and pressure topography: diagnostic advance or a new kid on the block? Curr Gastroenterol Rep 2014; 15:360. [PMID: 24271955 DOI: 10.1007/s11894-013-0360-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The recent development of closely spaced circumferential solid state transducers has paved the way for novel technology that includes high resolution anorectal manometry and topography (HRAM) and 3-D high definition anorectal manometry (HDAM). These techniques are increasingly being used for the assessment of anorectal neuromuscular function. However, whether they constitute a diagnostic advantage or a mere refinement of an old technology is unknown. Unlike the traditional manometry that utilized 3 or 6 unidirectional sensors, the closely spaced circumferential arrangement facilitates superior spatiotemporal mapping of pressures at rest and during various dynamic maneuvers. HDAM can provide knowledge of the three muscles that govern the anal continence namely, the puborectalis, and the internal and external anal sphincters, and can show how they mediate the rectoanal inhibitory reflex and sensorimotor responses and the spatiotemporal orientation of these muscles. Also, anal sphincter defects can be mapped and readily detected using 3-D technology. Similarly, HRAM has facilitated confirmation and development of phenotypes of dyssynergic defecation. Recently, normative data have also been reported with HRAM and HDAM, together with the influence of age, gender, and test instructions. The greater yield of anatomical and functional information may supersede the limitations of costs, fragility, and shorter life-span associated with these new techniques. Thus, HDAM and HRAM are not just new gadgets but constitute a significant and novel diagnostic advance. However, more prospective studies are needed to better define anorectal disorders with these techniques and to confirm their superiority.
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Affiliation(s)
- Yeong Yeh Lee
- Department of Medicine, Section of Gastroenterology & Hepatology, Georgia Regents University, 1120 15th Street, Augusta, GA, 30912, USA
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Cunin D, Siproudhis L, Desfourneaux V, Berkelmans I, Meunier B, Bretagne JF, Bouguen G. No surgery for full-thickness rectal prolapse: what happens with continence? World J Surg 2014; 37:1297-302. [PMID: 23440486 DOI: 10.1007/s00268-013-1967-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Surgery is the only validated means of treating overt rectal prolapses, but both patients and physicians may decline or postpone the surgical approach. However, little is known on the functional outcome of nonoperated rectal prolapse. The aim of the present study was to highlight the natural history of overt rectal prolapse in patients for whom surgery was avoided or delayed. PATIENTS AND METHODS A total of 206 patients complaining of full-thickness rectal prolapse were referred to a single institution that provided anorectal physiology for functional anorectal disorders. Standardized questionnaires, anorectal manometry, endosonography, and evacuation proctography constituted a prospective database. Fecal incontinence was evaluated with the Cleveland Clinic score (CCIS), and constipation was evaluated with the Knowles Eccersley Scott Symptom score (KESS). RESULTS Forty-two nonoperated patients (mean age: 61 ± 16 years) were compared to those of operated patients paired according to age and gender: the mean follow-up was 44 ± 26 months. The two groups had a similar past-history, follow-up, stool frequency, and main complaints, but lower quantified symptomatic scores and a better quality of life were reported in the nonsurgical group. At the end of follow-up, the nonsurgical group did not show any variation in CCI and KESS scores. By contrast, these two scores significantly improved in the rectopexy group. Sixteen nonoperated patients experienced a degradation of their continence status with an average increase of 5 ± 4.3 points of the CCIS. The patients with a CCIS <7 at referral were likely to deteriorate as compared to those having a higher score. Patients with a symptom history longer than 4 years never improved and in two-thirds continence deteriorated throughout the follow-up. CONCLUSION In the absence of the surgical option, patients with a 4-year duration of rectal prolapse and those with mild incontinence had no chance of improvement. These findings may be taken into account when surgery of rectal prolapse is not chosen.
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Affiliation(s)
- Diane Cunin
- CHU Rennes Service de Chirurgie Hépatobiliaire et Digestive, 35033, Rennes, France.
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Abstract
Surgical therapy of anal sphincter insufficiency is only indicated if it leads to symptoms and conservative treatment fails to achieve adequate symptom relief. Various new surgical options have evolved over the last decade but evidence of the efficacy varies substantially. Some have gained broader clinical acceptance based on the efficacy, ease of applicability and low risk profile. The paper aims to outline the currently commonly accepted and frequently applied surgical techniques for the treatment of anal sphincter insufficiency and the results, put these into the context of a treatment algorithm and to present novel techniques which carry potential for the future.
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Abstract
BACKGROUND Faecal incontinence is a distressing disorder with high social stigma. Not all people with faecal incontinence can be cured with conservative or surgical treatment and they may need to rely on containment products, such as anal plugs. OBJECTIVES To assess the performance of different types of anal plugs for containment of faecal incontinence. SEARCH METHODS We searched the Cochrane Incontinence Group Specialised Register (searched 29 February 2012). Reference lists of identified trials were searched and plugs manufacturers were contacted for trials. No language or other limitations were imposed. SELECTION CRITERIA Types of studies: This review was limited to randomised and quasi-randomised controlled trials (including crossovers) of anal plug use for the management of faecal incontinence. TYPES OF PARTICIPANTS Children and adults with faecal incontinence.Types of interventions: Any type of anal plug. Comparison interventions might include no treatment, conservative (physical) treatments, nutritional interventions, surgery, pads and other types or sizes of plugs. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed methodological quality and extracted data from the included trials. Authors of all included trials were contacted for clarification concerning methodological issues. MAIN RESULTS Four studies with a total of 136 participants were included. Two studies compared the use of plugs versus no plugs, one study compared two sizes of the same brand of plug, and one study compared two brands of plugs. In all included studies there was considerable dropout (in total 48 (35%) dropped out before the end of the study) for varying reasons. Data presented are thus subject to potential bias. 'Pseudo-continence' was, however, achieved by some of those who continued to use plugs, at least in the short-term. In a comparison of two different types of plug, plug loss was less often reported and overall satisfaction was greater during use of polyurethane plugs than polyvinyl-alcohol plugs. AUTHORS' CONCLUSIONS The available data were limited and incomplete, and not all pre-specified outcomes could be evaluated. Consequently, only tentative conclusions are possible. The available data suggest that anal plugs can be difficult to tolerate. However, if they are tolerated they can be helpful in preventing incontinence. Plugs could then be useful in a selected group of people either as a substitute for other forms of management or as an adjuvant treatment option. Plugs come in different designs and sizes; the review showed that the selection of the type of plug can impact on its performance.
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Affiliation(s)
- Marije Deutekom
- Department of SocialMedicine k2-207, AcademicMedical Center, Amsterdam,Netherlands.
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Bols E, Berghmans B, de Bie R, Govaert B, van Wunnik B, Heymans M, Hendriks E, Baeten C. Rectal balloon training as add-on therapy to pelvic floor muscle training in adults with fecal incontinence: A randomized controlled trial. Neurourol Urodyn 2011; 31:132-8. [DOI: 10.1002/nau.21218] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Accepted: 08/16/2011] [Indexed: 11/09/2022]
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Schwandner T, Hemmelmann C, Heimerl T, Kierer W, Kolbert G, Vonthein R, Weinel R, Hirschburger M, Ziegler A, Padberg W. Triple-target treatment versus low-frequency electrostimulation for anal incontinence: a randomized, controlled trial. DEUTSCHES ARZTEBLATT INTERNATIONAL 2011; 108:653-60. [PMID: 22013492 DOI: 10.3238/arztebl.2011.0653] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Accepted: 07/20/2011] [Indexed: 11/27/2022]
Abstract
BACKGROUND In the nonsurgical treatment of anal incontinence, the combination of amplitude-modulated medium-frequency stimulation and electromyographic biofeedback (EMG-BF), known as triple-target treatment (3T), is superior to EMG-BF alone. The aim of this trial is to compare 3T with the standard treatment, low-frequency stimulation (LFS). METHODS 80 patients with anal incontinence of Grade I or higher who presented to physicians or centers specialized in coloproctology were enrolled in this multicenter randomized trial with blinded observer. The trial had an open parallel-group design. Randomization was performed centrally by telephone. The primary endpoint was the Cleveland Clinic Score (CCS) after self-training at home with either 3T or LFS in two 20-minute sessions per day for 6 months. The secondary endpoints included the proportion of patients regaining continence, and the patients' quality of life (QoL). On completion of the trial as planned, the results were evaluated with an intention-to-treat analysis. STUDY REGISTRATION DRKS00000138 (http://register.germanctr.de). RESULTS 39 patients were randomized to 3T, and 41 to LFS. After 6 months of treatment, the CCS (mean ± standard deviation) was 3.1 ± 4.2 in the 3T group and 9.6 ± 3.9 in the LFS group. The median improvement in the CCS at 6 months compared to baseline was 7 points greater in the 3T group than in the LFS group (95% CI: 5-9, p<0.001). Anal continence was regained by 54% of the 3T patients, but none of the LFS patients (95% CI for the difference: 37.18% - 69.91%, p<0.001). QoL scores were higher in all dimensions in the 3T group than in the LFS group. No major adverse effects occurred in either group. CONCLUSION 3T is superior to LFS in the treatment of anal incontinence. The available evidence suggests that the success of 3T is based on the combined effect of biofeedback and medium-frequency stimulation. LFS of the type applied in this trial has no effect. 3T should be used in routine clinical practice instead of LFS.
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Affiliation(s)
- Thilo Schwandner
- Klinik für Allgemein-, Viszeral-, Thorax- und Transplantationschirurgie, Fachbereich Medizin, Justus-Liebig-Universität Giessen
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Is cesarean section a real panacea to prevent pelvic organ disorders? Int Urogynecol J 2011; 22:1135-41. [DOI: 10.1007/s00192-011-1457-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2011] [Accepted: 05/10/2011] [Indexed: 11/27/2022]
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Abstract
Biofeedback is a clinical modality in which technology or instrumentation is used to allow a patient to gain awareness of, and control over, physiologic processes. Successful treatment employing biofeedback can be beneficial for several stress-related and pain conditions, as well as other forms of somatic disturbance. Collectively, the same conditions that may respond to biofeedback are those often seen in a primary care practice and are conditions that can result in chronic dysfunction and disability. Understanding the forms and uses of biofeedback, the research evidence base, and practical referral guidelines can help the family physician to offer recommendations and referrals to patients.
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Affiliation(s)
- Ronald M Glick
- Department of Psychiatry, Physical Medicine and Rehabilitation, and Family Medicine, University of Pittsburgh School of Medicine, 580 South Aiken Suite 310, Pittsburgh, PA 15232, USA.
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Savitt L, Thurler A. Biofeedback for Constipation and Fecal Incontinence. SEMINARS IN COLON AND RECTAL SURGERY 2011. [DOI: 10.1053/j.scrs.2010.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Gié O, Christoforidis D. Advances in the Treatment of Fecal Incontinence. SEMINARS IN COLON AND RECTAL SURGERY 2011. [DOI: 10.1053/j.scrs.2010.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Findlay JM, Maxwell-Armstrong C. Posterior tibial nerve stimulation and faecal incontinence: a review. Int J Colorectal Dis 2011; 26:265-73. [PMID: 21069357 DOI: 10.1007/s00384-010-1085-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/27/2010] [Indexed: 02/04/2023]
Abstract
PURPOSE Faecal incontinence is a common and important multifactorial disorder with a range of treatment options. Over the last two decades, neuromodulation via sacral nerve stimulators has been shown to be effective for both faecal and urinary incontinence, although associated with complications. Peripheral neuromodulation, via the posterior tibial nerve, is widely used in urinary incontinence; however, its use in faecal incontinence, whilst evolving is limited to eight small heterogeneous studies. REVIEW These eight studies are discussed in the context of the methodology and underlying neurophysiology of peripheral neuromodulation, as are thus far unanswered questions. The eight studies include a total of 129 patients with faecal incontinence (of variable aetiology), all of whom had failed conservative management. One study was prospective and controlled, six were uncontrolled and one was retrospective and uncontrolled. Five different neuromodulatory protocols were used over six different study periods. Outcome measures varied, but short term primary endpoint success ranged from 30.0% to 83.3%. The limitations to this early evidence, whilst encouraging, are significant, and it remains to be seen whether this novel treatment modality represents the minimally invasive, well-tolerated, cost-effective and flexible panacea hoped for this common and debilitating disease. Three upcoming multicentre placebo-controlled trials will better be able to delineate its role.
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Affiliation(s)
- John M Findlay
- Department of General Surgery, Royal Berkshire Hospital, Reading RG1 5AN, UK.
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Westra BL, Savik K, Oancea C, Choromanski L, Holmes JH, Bliss D. Predicting improvement in urinary and bowel incontinence for home health patients using electronic health record data. J Wound Ostomy Continence Nurs 2011; 38:77-87. [PMID: 21287773 PMCID: PMC3057761 DOI: 10.1097/won.0b013e318202e4a6] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of the study was to discover which patient and support system characteristics and interventions documented by home health clinicians were associated with improvement in urinary and bowel incontinence contrasting logistic regression and data mining approaches. SUBJECTS AND SETTING Seventeen hundred ninety-three patients in this study experienced 2072 episodes of care. The study sample comprised all nonmaternity patients aged 18 years or older receiving skilled home health services in 2004. Subjects were drawn from a convenience sample of 15 home health agencies . DESIGN We completed a secondary analysis of data from 15 home health agencies' electronic health records. Data for this study were documented by home care clinicians using the Outcome and Assessment Information Set (OASIS) structured assessment form and the Omaha System interventions, which is a standardized terminology. RESULTS There were 684 patients with urinary incontinence and 187 with bowel incontinence. By discharge 38% improved in urinary incontinence and 45% improved their bowel incontinence. Using logistic regression, no patient or support system characteristics were identified that associated with improvement in either urinary or bowel incontinence, only a limited number of interventions were significant. A data mining decision tree was producible only for bowel incontinence, demonstrating a combination of patient and support system factors as well as selected interventions were important in determining whether patients would improve in bowel incontinence. CONCLUSIONS Home health patients have complex comorbid conditions requiring home care nurses to have broad, generalized knowledge. Future research is needed to determine if the inclusion of a certified WOC nurse would improve outcomes.
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Affiliation(s)
- Bonnie L Westra
- School of Nursing, University of Minnesota, 6-135 Weaver-Densford Hall, Minneapolis, MN 55455, USA.
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Findlay J, Maxwell-Armstrong C. Posterior tibial nerve stimulation for faecal incontinence. ACTA ACUST UNITED AC 2010; 19:750-4. [PMID: 20622793 DOI: 10.12968/bjon.2010.19.12.48652] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Faecal incontinence is a common multifactorial condition with a range of invasive treatment options, all of which may be associated with significant complications. Posterior tibial stimulation by continence nurses is an established treatment for urinary incontinence; however, its use in faecal incontinence, while rapidly evolving, is limited to eight small and differing studies. In this article, the background of current management options for faecal incontinence is discussed, as are the physiology and evidence underlying neuromodulation. The evidence base for posterior tibial nerve stimulation in faecal incontinence is reviewed, as well as the implications for practice and further research. While this early evidence base is encouraging, it has yet to be established whether this novel approach may be the minimally invasive, effective and cheap treatment hoped for, for this common and debilitating condition.
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Affiliation(s)
- John Findlay
- Department of General Surgery, Horton General Hospital, Banbury
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Findlay JM, Yeung JMC, Robinson R, Greaves H, Maxwell-Armstrong C. Peripheral neuromodulation via posterior tibial nerve stimulation - a potential treatment for faecal incontinence? Ann R Coll Surg Engl 2010; 92:385-90. [PMID: 20626970 DOI: 10.1308/003588410x12628812459652] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Faecal incontinence is a prevalent and important condition, with a range of treatment options. Neuromodulation via sacral nerve stimulators is efficacious, but expensive and associated with complications due to device implantation. Peripheral neuromodulation via posterior tibial nerve stimulation (PTNS) has been assessed in urinary incontinence, but there is minimal evidence for its use in faecal incontinence and no literature from the UK. This retrospective review aimed to assess the efficacy of PTNS in faecal incontinence. PATIENTS AND METHODS Thirteen consecutive female patients with faecal incontinence of various causes (9 idiopathic, 3 obstetric, 1 surgery) underwent PTNS at a UK hospital. All were investigated with colonic imaging, anorectal physiology and endo-anal ultrasound. Prior treatments included physiotherapy (13), sphincteroplasty (3) biofeedback (3) and PTQ implants (1). PTNS was performed for 30 min, weekly for 12 weeks. RESULTS Median monthly episodes of incontinence of wind, liquid and solid reduced from 6, 10 and 18 respectively to 0 with 12 weeks' treatment (P < 0.05). Significant improvements in quality of life indices were also seen. At 1-month follow up, a sustained reduction in incontinence of wind was seen (0 episodes), with non-significant reductions of liquid and solid stool. CONCLUSIONS PTNS is a potentially efficacious, technically simple and minimally invasive alternative treatment modality for faecal incontinence. These early results are encouraging, but we await medium- and long-term follow-up, and a larger randomised trial comparing PTNS with alternative treatments and placebo.
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Affiliation(s)
- John M Findlay
- Department of Digestive Diseases and Thoracics, Queen's Medical Centre, Nottingham, UK.
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Findlay JM, Maxwell-Armstrong C. Current issues in the management of adult faecal incontinence. Br J Hosp Med (Lond) 2010; 71:335-40. [DOI: 10.12968/hmed.2010.71.6.48446] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Evaluation and treatment of anal incontinence, constipation, and defecatory dysfunction. Obstet Gynecol Clin North Am 2010; 36:673-97. [PMID: 19932421 DOI: 10.1016/j.ogc.2009.08.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Posterior compartment disorders include anal incontinence, constipation, and defecatory dysfunction. These disorders cause considerable morbidity, and are typically underreported by patients and undertreated by providers. The purpose of this article is outline the approach to diagnosis and treatment of anal incontinence, constipation, and defecatory dysfunction with a brief description of the nature of the problem and approaches to evaluation and diagnosis, as well as medical and surgical management.
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Norton C, Whitehead WE, Bliss DZ, Harari D, Lang J. Management of fecal incontinence in adults. Neurourol Urodyn 2010; 29:199-206. [PMID: 20025031 DOI: 10.1002/nau.20803] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
This article summarises the findings from the Conservative Management of Faecal Incontinence in Adults Committee of the International Consultation on Incontinence. We conducted comprehensive literature searches using the following keywords combined with the relevant intervention: "anal, anorectal, bowel, faecal, fecal, rectal, stool" and "continent$ or incontinent$," Prevalence etimates for faecal or anal incontinence vary widely, from 2.2% to 2.5%. Expert opinion supports the use of general health education, patient teaching about bowel function and advice on lifestyle modification, but the evidence base is small. Unlike urinary incontinence, few "lifestyle" associations have been identified with FI and little is known about whether interventions designed to reduce potential risk factors might improve FI. The article summarises the evidence and recommendations from the committee for clinical practice and future research.
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Affiliation(s)
- C Norton
- King's College London, Florence Nightingale School of Nursing & Midwifery, London, UK.
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Prevalence of major levator abnormalities in symptomatic patients with an underactive pelvic floor contraction. Int Urogynecol J 2010; 21:861-7. [PMID: 20204327 PMCID: PMC2876255 DOI: 10.1007/s00192-010-1111-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2009] [Accepted: 01/11/2010] [Indexed: 11/09/2022]
Abstract
Introduction and hypothesis Major levator ani abnormalities (LAA) may lead to abnormal pelvic floor muscle contraction (pfmC) and secondarily to stress urinary incontinence (SUI), prolapse, or fecal incontinence (FI). Methods A retrospective observational study included 352 symptomatic patients to determine prevalence of LAA in underactive pfmC and the relationship with symptoms. On 2D/3D transperineal ultrasound, PfmC was subjectively assessed as underactive (UpfmC) or normal (NpfmC) and quantified. LAA, defined as a complete avulsion of the pubic bone, was analyzed using tomographic ultrasound imaging. Results LAA were found in 53.8% of women with UpfmC versus 16.1% in NpfmC (P < 0.001). Patients with UpfmC were less likely to reduce hiatal area on pfmC (mean 7% reduction vs 25% in NpfmC (P < 0.001)). An UpfmC was associated with FI (P = 0.002), not with SUI or prolapse of the anterior and central compartment. Conclusion An underactive pfmC is associated with increased prevalence of LAA and FI.
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Enck P, Van der Voort IR, Klosterhalfen S. Biofeedback therapy in fecal incontinence and constipation. Neurogastroenterol Motil 2009; 21:1133-41. [PMID: 19566591 DOI: 10.1111/j.1365-2982.2009.01345.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
We examine the collected evidence for efficacy of biofeedback therapy (BFT) in incontinence and constipation by means of meta-analysis of randomized controlled trials. PubMed search was performed to identify treatment trials that match quality criteria (adequate control groups, randomization). They were entered into meta-analyses using fixed effect models and computing odds ratio (OR) and 95% confidence interval (CI) of treatment effects. For constipation, eight BFT trials were identified. In four trials, electromyographic (EMG) BFT was compared to non-BFT treatments (laxatives, placebo, sham training and botox injection), while in the remaining four studies EMG BFT was compared to other BFT (balloon pressure, verbal feedback) modes. Meta-analyses revealed superiority of BFT to non-BFT (OR: 3.657; 95% CI: 2.127-6.290, P < 0.001) but equal efficacy of EMG BFT to other BF applications (OR: 1.436; CI: 0.692-3.089; P = 0.319). For fecal incontinence, a total of 11 trials were identified, of which six compared BFT to other treatment options (sensory training, pelvic floor exercise and electrical stimulation) and five compared one BFT option to other modalities of BFT. BFT was equal effective than non-BFT therapy (OR: 1.189, CI: 0.689-2.051, P = 0.535). No difference was found when various modes BFT were compared (OR: 1.278, CI: 0.736-2.220, P = 0.384). Included trials showed a substantial lack of quality and harmonization, e.g. variable endpoints and missing psychological assessment across studies. BFT for pelvic floor dyssynergia shows substantial specific therapeutic effect while BFT for incontinence is still lacking evidence for efficacy. However, in both conditions the mode of BFT seems to play a minor role.
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Affiliation(s)
- P Enck
- University Hospital, Department of Psychosomatic Medicine and Psychotherapy, Tübingen, Germany.
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Maeda Y, Laurberg S, Norton CS. Perianal injectable bulking agents as treatment for faecal incontinence. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2009. [DOI: 10.1002/14651858.cd007959] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Investigating and treating fecal incontinence: when and how. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2009; 23:301-8. [PMID: 19373424 DOI: 10.1155/2009/905359] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Fecal incontinence is a common disorder in our aging population and can have profound effects on patient's well-being. The present review examines the current understanding of fecal incontinence and provides a practical approach to the investigation and management of this condition. A special emphasis is placed on specialized testing, focusing on indications and impact on guiding management.
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Hay-Smith J, Mørkved S, Fairbrother KA, Herbison GP. Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database Syst Rev 2008:CD007471. [PMID: 18843750 DOI: 10.1002/14651858.cd007471] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND About a third of women have urinary incontinence and up to a tenth have faecal incontinence after childbirth. Pelvic floor muscle training is commonly recommended during pregnancy and after birth both for prevention and treatment of incontinence. OBJECTIVES To determine the effect of pelvic floor muscle training compared to usual antenatal and postnatal care on incontinence. SEARCH STRATEGY We searched the Cochrane Incontinence Group Specialised Register (searched 24 April 2008) and the references of relevant articles. SELECTION CRITERIA Randomised or quasi-randomised trials in pregnant or postnatal women. One arm of the trials needed to include pelvic floor muscle training (PFMT). Another arm was either no pelvic floor muscle training or usual antenatal or postnatal care. The pelvic floor muscle training programmes were divided into either: intensive; or unspecified if training elements were lacking or information was not provided. Reasons for classifying as intensive included one to one instruction, checking for correct contraction, continued supervision of training, or choice of an exercise programme with sufficient exercise dose to strengthen muscle. DATA COLLECTION AND ANALYSIS Trials were independently assessed for eligibility and methodological quality. Data were extracted then cross checked. Disagreements were resolved by discussion. Data were processed as described in the Cochrane Handbook. Three different populations of women were considered separately: women dry at randomisation (prevention); women wet at randomisation (treatment); and a population-based approach in women who might be one or the other (prevention or treatment). Trials were further divided into: those which started during pregnancy (antenatal); and after delivery (postnatal). MAIN RESULTS Sixteen trials met the inclusion criteria. Fifteen studies involving 6181 women (3040 PFMT, 3141 controls) contributed to the analysis. Based on the trial reports, four trials appeared to be at low risk of bias, two at low to moderate risk, and the remainder at moderate risk of bias.Pregnant women without prior urinary incontinence who were randomised to intensive antenatal PFMT were less likely than women randomised to no PFMT or usual antenatal care to report urinary incontinence in late pregnancy (about 56% less; RR 0.44, 95% CI 0.30 to 0.65) and up to six months postpartum (about 30% less; RR 0.71, 95% CI 0.52 to 0.97).Postnatal women with persistent urinary incontinence three months after delivery and who received PFMT were less likely than women who did not receive treatment or received usual postnatal care (about 20% less; RR 0.79, 95% CI 0.70 to 0.90) to report urinary incontinence 12 months after delivery. It seemed that the more intensive the programme the greater the treatment effect. Faecal incontinence was also reduced at 12 months after delivery: women receiving PFMT were about half as likely to report faecal incontinence (RR 0.52, 95% CI 0.31 to 0.87).Based on the trial data to date, the extent to which population-based approaches to PFMT are effective is less clear (that is, offering advice on PFMT to all pregnant or postpartum women whether they have incontinence symptoms or not). It is possible that population-based approaches might be effective when the intervention is intensive enough.There was not enough evidence about long-term effects for either urinary or faecal incontinence. AUTHORS' CONCLUSIONS There is some evidence that PFMT in women having their first baby can prevent urinary incontinence in late pregnancy and postpartum. In common with older women with stress incontinence, there is support for the widespread recommendation that PFMT is an appropriate treatment for women with persistent postpartum urinary incontinence. It is possible that the effects of PFMT might be greater with targeted rather than population-based approaches and in certain groups of women (for example primiparous women; women who had bladder neck hypermobility in early pregnancy, a large baby, or a forceps delivery). These and other uncertainties, particularly long-term effectiveness, require further testing.
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Affiliation(s)
- Jean Hay-Smith
- Rehabilitation Teaching and Research Unit, Department of Medicine, Wellington School of Medicine and Health Sciences, University of Otago, PO Box 7343, Wellington South, Wellington, New Zealand.
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Abstract
Marilyne Lange and Cornelis van de Velde discuss the differential diagnosis and management of incontinence after rectal cancer treatment.
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Affiliation(s)
- Maureen Coggrave
- National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury, Buckinghamshire and the Burdett Institute of Gastrointestinal Nursing, St Mark’s Hospital, Harrow, and Lecturer, King’s College London
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Faucheron JL. [Anal incontinence]. Presse Med 2008; 37:1447-62. [PMID: 18555639 DOI: 10.1016/j.lpm.2008.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2007] [Revised: 01/26/2008] [Accepted: 04/21/2008] [Indexed: 12/15/2022] Open
Abstract
Anal incontinence today is more frequent than current estimates indicate. When a patient seeks care for this condition, its cause and severity are assessed by a careful history and clinical examination. Two essential atraumatic examinations are decision-support tools: transrectal ultrasound and anal manometry. Treatment should always be proposed. Surgery is necessary in some cases: obvious rupture of the external sphincter, if possible confirmed by transrectal ultrasound, should be directly repaired. Should this treatment fail, a repeated repair or a sphincter replacement (graciloplasty or artificial sphincter) is called for. Neuromodulation therapy is often indicated in the absence of obvious rupture, especially in cases of pudendal neuropathy.
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Affiliation(s)
- Jean-Luc Faucheron
- Unité de chirurgie colorectale, Clinique universitaire de chirurgie digestive et de l'urgence, Hôpital Albert Michallon, F-38043 Grenoble cedex 9, France.
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Mion F, Roman S, Barth X, Damon H. [What's new in the treatment of fecal incontinence?]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2008; 32:S240-S245. [PMID: 18462900 DOI: 10.1016/j.gcb.2008.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- F Mion
- Hospices civils de Lyon, exploration fonctionnelle digestive, hôpital Edouard-Herriot, 5, place d'Arsonval, 69374 Lyon cedex 03, France.
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Domsic R, Fasanella K, Bielefeldt K. Gastrointestinal manifestations of systemic sclerosis. Dig Dis Sci 2008; 53:1163-74. [PMID: 17934861 DOI: 10.1007/s10620-007-0018-8] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2007] [Accepted: 09/07/2007] [Indexed: 12/12/2022]
Abstract
Systemic sclerosis is a chronic disorder of connective tissue that affects the gastrointestinal tract in more than 80% of patients. Changes in neuromuscular function with progressive fibrosis of smooth muscle within the muscularis propria impair normal motor function, which may secondarily alter transit and nutrient absorption. Esophageal manifestations with gastroesophageal reflux and dysphagia are the most common visceral manifestation of the disease, often requiring more intense acid-suppressive medication. Gastric involvement may lead to gastroparesis, which can be found in up to 50% of patients. Severe small bowel disease can present as chronic intestinal pseudo-obstruction with distended loops of small intestine, bacterial overgrowth, impaired absorption and progressive development of nutritional deficiencies. While not studied as extensively, systemic sclerosis often also affects colorectal function resulting in constipation, diarrhea or fecal incontinence. Nutritional support and prokinetics have been used with some success to manage gastric and small or large bowel involvement in patients with systemic sclerosis. Despite advances in management, significant gastrointestinal manifestations of systemic sclerosis still carry a poor prognosis with a five-year mortality exceeding 50%.
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Affiliation(s)
- Robyn Domsic
- Division of Rheumatology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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Szojda MM, Tanis E, Mulder CJJ, Felt-Bersma RJF. Referral for anorectal function evaluation is indicated in 65% and beneficial in 92% of patients. World J Gastroenterol 2008; 14:272-7. [PMID: 18186567 PMCID: PMC2675126 DOI: 10.3748/wjg.14.272] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine the indicated referrals to a tertiary centre for patients with anorectal symptoms, the effect of the advised treatment and the discomfort of the tests.
METHODS: In a retrospective study, patients referred for anorectal function evaluation (AFE) between May 2004 and October 2006 were sent a questionnaire, as were the doctors who referred them. AFE consisted of anal manometry, rectal compliance measurement and anal endosonography. An indicated referral was defined as needing AFE to establish a diagnosis with clinical consequence (fecal incontinence without diarrhea, 3rd degree anal sphincter rupture, congenital anorectal disorder, inflammatory bowel disease with anorectal complaints and preoperative in patients for re-anastomosis or enterostoma, anal fissure, fistula or constipation). Anal ultrasound is always indicated in patients with fistula, anal manometry and rectal compliance when impaired continence reserve is suspected. The therapeutic effect was noted as improvement, no improvement but reassurance, and deterioration.
RESULTS: From the 216 patients referred, 167 (78%) returned the questionnaire. The referrals were indicated in 65%. Of these, 80% followed the proposed advice. Improvement was achieved in 35% and a reassurance in 57% of the patients, no difference existed between patient groups. On a VAS scale (1 to 10) symptoms improved from 4.0 to 7.2. Most patients reported no or little discomfort with AFE.
CONCLUSION: Referral for AFE was indicated in 65%. Beneficial effect was seen in 92%: 35% improved and 57% was reassured. Advice was followed in 80%. Better instruction about indication for AFE referral is warranted.
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Bols EMJ, Berghmans BCM, Hendriks EJM, de Bie RA, Melenhorst J, van Gemert WG, Baeten CGMI. A randomized physiotherapy trial in patients with fecal incontinence: design of the PhysioFIT-study. BMC Public Health 2007; 7:355. [PMID: 18096041 PMCID: PMC2234416 DOI: 10.1186/1471-2458-7-355] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2007] [Accepted: 12/20/2007] [Indexed: 01/29/2023] Open
Abstract
Background Fecal incontinence (FI) is defined as the recurrent involuntary excretion of feces in inappropriate places or at inappropriate times. It is a major and highly embarrassing health care problem which affects about 2 to 24% of the adult population. The prevalence increases with age in both men and women. Physiotherapy interventions are often considered a first-line approach due to its safe and non-invasive nature when dietary and pharmaceutical treatment fails or in addition to this treatment regime. Two physiotherapy interventions, rectal balloon training (RBT) and pelvic floor muscle training (PFMT) are widely used in the management of FI. However, their effectiveness remains uncertain since well-designed trials on the effectiveness of RBT and PFMT versus PFMT alone in FI have never been published. Methods/Design A two-armed randomized controlled clinical trial will be conducted. One hundred and six patients are randomized to receive either PFMT combined with RBT or PFMT alone. Physicians in the University Hospital Maastricht include eligible participants. Inclusion criteria are (1) adults (aged ≥ 18 years), (2) with fecal incontinence complaints due to different etiologies persisting for at least six months, (3) having a Vaizey incontinence score of at least 12, (4) and failure of conservative treatment (including dietary adaptations and pharmacological agents). Baseline measurements consist of the Vaizey incontinence score, medical history, physical examination, medication use, anorectal manometry, rectal capacity measurement, anorectal sensation, anal endosonography, defecography, symptom diary, Fecal Incontinence Quality of Life scale (FIQL) and the PREFAB-score. Follow-up measurements are scheduled at three, six and 12 months after inclusion. Skilled and registered physiotherapists experienced in women's health perform physiotherapy treatment. Twelve sessions are administered during three months according to a standardized protocol. Discussion This section discusses the decision to publish a trial protocol, the actions taken to minimize bias and confounding in the design, explains the choice for two treatment groups, discusses the secondary goals of this study and indicates the impact of this trial on clinical practice. Trial registration The Netherlands Trial Register ISRCTN78640169.
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Affiliation(s)
- Esther M J Bols
- Department of Epidemiology, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands.
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Naimy N, Lindam AT, Bakka A, Faerden AE, Wiik P, Carlsen E, Nesheim BI. Biofeedback vs. electrostimulation in the treatment of postdelivery anal incontinence: a randomized, clinical trial. Dis Colon Rectum 2007; 50:2040-6. [PMID: 17914654 DOI: 10.1007/s10350-007-9075-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2006] [Revised: 05/30/2007] [Accepted: 06/09/2007] [Indexed: 02/08/2023]
Abstract
PURPOSE This study was designed to evaluate the effect of biofeedback and electrostimulation in a randomized, clinical trial for the treatment of patients with postdelivery anal incontinence. METHODS Forty-nine females who sustained third-degree or fourth-degree perineal rupture with a mean age of 36 (range, 22-44) years were included in the study. The females were randomized to biofeedback or electrostimulation treatment. Forty females completed the study: 19 in the biofeedback and 21 in the electrostimulation group. Biofeedback or electrostimulation sessions were performed two times daily for eight weeks in each group. Wexner incontinence score, fecal incontinence quality of life scores, and reduced quality of life on visual analog scale were registered before and after treatment. Patients' self-rating of treatment effect also was registered in both groups. The primary outcome measure was the Wexner incontinence score. RESULTS There were no differences in treatment effect between groups. Comparing pretreatment status to posttreatment in each group showed no improvement in Wexner score, reduced quality of life, or any of the fecal incontinence quality of life scores. Patients' self-rating of the treatment effect, however, showed a subjective improvement of symptoms both in the biofeedback and in the electrostimulation group (median, 7 vs. 5.) CONCLUSIONS This study shows that there was no difference in effect between biofeedback and electrostimulation. Neither biofeedback nor electrostimulation treatments improved Wexner incontinence score, reduced quality of life, or fecal incontinence quality of life scores. Both treatments resulted in improvement of patients' subjective perception of incontinence control.
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Affiliation(s)
- Nazir Naimy
- Department of Surgery, Akershus University Hospital, Oslo University, Lorenskog, Norway.
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How should clinical psychologists approach complementary and alternative medicine? Empirical, epistemological, and ethical considerations. Clin Psychol Rev 2007; 28:657-75. [PMID: 17996344 DOI: 10.1016/j.cpr.2007.09.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2007] [Revised: 09/24/2007] [Accepted: 09/24/2007] [Indexed: 11/21/2022]
Abstract
As complementary and alternative medicine (CAM) practices are often recommended for mental health problems, many clients in clinical psychology will be in receipt of such treatments from other practitioners. Some psychologists have argued that CAM and psychology are natural bedfellows, given their sharing of philosophies (e.g., holism), professional orientations (e.g., person-centeredness), and theoretical positions (e.g., mind-body connectionism). It has specifically been argued that the practices of CAM could productively be appropriated, or at least promoted, by clinical psychologists. However, other commentators have criticized CAM for comprising therapies that, by definition, are both intrinsically unscientific and lacking in empirical evidence. This article examines the current standing of CAM from empirical, epistemological, and ethical perspectives. CAM treatments are found to be based on heterogeneous epistemologies and to suffer from poor records in empirical efficacy research. Attention is given to possible psychological explanations for CAM's popularity in the face of poor evidence for efficacy. It is argued that, given the likely incompatibility of CAM with clinical psychology's positivist scientific ethos, CAM practices should not be integrated into clinical psychology at this time.
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Abstract
Anorectal motor disorders such as faecal incontinence, chronic anorectal pain and solitary rectal ulcer syndrome are common in the community. They cause psychological distress, affect quality of life, and pose a significant economic burden. In recent years, many strides have been made in the diagnostic criteria and in the mechanistic understanding of anorectal disorders. The use of innovative manometric, neurophysiological and radiological techniques have shed new light on the underlying pathophysiology. Also, it has been recognised that psychological dysfunction play an important role. However, there is a lack of consensus regarding what is abnormal, regarding the overlap between phenotypes and regarding optimal diagnostic approaches or tests. There has been little advance in drug therapy for these conditions. Although several treatments have been tried and appear promising, controlled trials are either lacking or have provided insignificant evidence. There is a need for improved medical, behavioural and surgical treatments for these conditions.
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Affiliation(s)
- Jose M Remes-Troche
- Section of Neurogastroenterology, Division of Gastroenterology-Hepatology, Department of Internal Medicine University of Iowa Carver College of Medicine & Clinical Research Center, Iowa City, IA 52242, USA
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Mowatt G, Glazener C, Jarrett M. Sacral nerve stimulation for faecal incontinence and constipation in adults. Cochrane Database Syst Rev 2007:CD004464. [PMID: 17636759 DOI: 10.1002/14651858.cd004464.pub2] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Faecal incontinence and constipation are disabling conditions that reduce quality of life. If conservative treatment fails, one option is sacral nerve stimulation (SNS), a minimally invasive technique allowing modulation of the nerves and muscles of the pelvic floor and hindgut. OBJECTIVES To assess the effects of SNS for faecal incontinence and constipation in adults. SEARCH STRATEGY We searched the Cochrane Incontinence Group Specialised Trials Register (searched 24 April 2007) and the reference lists of relevant articles. SELECTION CRITERIA All randomised or quasi-randomised trials assessing the effects of SNS for faecal incontinence or constipation in adults. DATA COLLECTION AND ANALYSIS Two review authors independently screened the search results, assessed the methodological quality of the included studies, and undertook data extraction. MAIN RESULTS Three crossover studies were included. Two, enrolling 34 (Leroi) and two participants (Vaizey), assessed the effects of SNS for faecal incontinence, and one (Kenefick), enrolling two participants, assessed SNS for constipation. In the study by Leroi, following the crossover period, participants, while still blinded, chose the period of stimulation they had preferred. Outcomes at different time points were reported separately for 19 participants who preferred the 'on' and five who preferred the 'off' period. For the group of 19, the median (range) episodes of faecal incontinence per week fell from 1.7 (0 to 9) during the 'off' period to 0.7 (0 to 5) during the 'on' period; for the group of five, however, the median (range) rose from 1.7 (0 to 11) during the 'off' period compared with 3.7 (0 to 11) during the 'on' period. Vaizey reported an average of six, and one, episodes of faecal incontinence per week during the 'off' and 'on' periods respectively. Leroi reported that four of 27 participants experienced an adverse event resulting in removal of the stimulator; Vaizey did not report adverse events. For SNS for constipation, during the 'off' crossover period the participants experienced an average of two bowel movements per week, compared with five during the 'on' period. Abdominal pain and bloating occurred 79% of the time during the 'off' period compared with 33% during the 'on' period. No adverse events occurred. AUTHORS' CONCLUSIONS The very limited evidence from the included studies suggests that SNS can improve continence in selected people with faecal incontinence, and reduce symptoms in selected people with constipation. However temporary, percutaneous stimulation for a two-to-three week period does not always successfully identify those for whom a permanent implant will be beneficial. Larger, good quality randomised crossover trials are needed to allow the effects of SNS for these conditions to be assessed with more certainty.
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Affiliation(s)
- G Mowatt
- University of Aberdeen, Health Services Research Unit, 3rd Floor, Health Sciences Building, Foresterhill, Aberdeen, UK, AB25 2ZD.
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Abstract
BACKGROUND Faecal incontinence is a particularly embarrassing and distressing condition with significant medical, social and economic implications. Electrical stimulation has been used with apparent success in the treatment of faecal incontinence. However, standards of treatment are still lacking and the magnitude of alleged benefits has yet to be established. OBJECTIVES To determine the effects of electrical stimulation for the treatment of faecal incontinence in adults. SEARCH STRATEGY We searched the Cochrane Incontinence Group Specialised Trials Register (searched 13 March 2007) and reference lists of potentially eligible articles. SELECTION CRITERIA All randomised or quasi-randomised trials evaluating electrical stimulation in adults with faecal incontinence. DATA COLLECTION AND ANALYSIS Two reviewers assessed the methodological quality of potentially eligible trials and independently extracted data from the included trials. A wide range of outcome measures were considered. MAIN RESULTS Four eligible trials with 260 participants were identified. Findings from one trial suggest that electrical stimulation with anal biofeedback and exercises provides more short-term benefits than vaginal biofeedback and exercises for women with obstetric-related faecal incontinence. Another study found contradictory results, with no added benefit from electrical stimulation over biofeedback and exercises alone. Although all trials report that patient's symptoms are generally improved, it is not clear that this is the effect of electrical stimulation. No further conclusions could be drawn from the data available. AUTHORS' CONCLUSIONS At present, there are insufficient data to allow reliable conclusions to be drawn on the effects of electrical stimulation in the management of faecal incontinence. There is a suggestion that electrical stimulation may have a therapeutic effect, but this is not certain. Larger, more generalisable trials are needed.
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Affiliation(s)
- G Hosker
- St Mary's Hospital, Warrell Unit, Hathersage Road, Manchester, UK M13 OJH.
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Abstract
BACKGROUND Faecal incontinence is a distressing disorder with high social stigma. Not all people with faecal incontinence can be cured with conservative or surgical treatment and they may need to rely on containment products, such as anal plugs. OBJECTIVES To assess the performance of different types of anal plugs for containment of faecal incontinence. SEARCH STRATEGY We searched the Cochrane Incontinence Group Specialised Register (searched 22 November 2004), MEDLINE (January 1966 to November 2004), CINAHL (January 1982 to November Week 3 2004), EMBASE (January 1996 to 2004 Week 47), INVERT (Dutch nursing database) (January 1993 to November 2004) and Web of Science (January 1988 to November 2004). Reference lists of identified trials were searched and plugs manufacturers were contacted for trials. No language or other limitations were imposed. SELECTION CRITERIA Types of studies: This review was limited to randomised and quasi-randomised controlled trials (including crossovers) of anal plug use for the management of faecal incontinence. TYPES OF PARTICIPANTS Children and adults with faecal incontinence. Types of interventions: Any type of anal plug. Comparison interventions might include no treatment, conservative (physical) treatments, nutritional interventions, surgery, pads and other types or sizes of plugs. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed methodological quality and extracted data from the included trials. Authors of all included trials were contacted for clarification concerning methodological issues. MAIN RESULTS Four studies with a total of 136 participants were included. Two studies compared the use of plugs versus no plugs, one study compared two sizes of the same brand of plug, and one study compared two brands of plugs. In all included studies there was considerable dropout (in total 48 (35%) dropped out before the end of the study) for varying reasons. Data presented are thus subject to potential bias. 'Pseudo-continence' was, however, achieved by some of those who continued to use plugs, at least in the short-term. In a comparison of two different types of plug, plug loss was less often reported and overall satisfaction was greater during use of polyurethane plugs than polyvinyl-alcohol plugs. AUTHORS' CONCLUSIONS The available data were limited and incomplete, and not all pre-specified outcomes could be evaluated. Consequently, only tentative conclusions are possible. The available data suggest that anal plugs can be difficult to tolerate. However, if they are tolerated they can be helpful in preventing incontinence. Plugs could then be useful in a selected group of people either as a substitute for other forms of management or as an adjuvant treatment option. Plugs come in different designs and sizes; the review showed that the selection of the type of plug can impact on its performance.
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Affiliation(s)
- M Deutekom
- Clinical Epidemiology and Biostatistics, AMC, Meibergdreef 9, j1b-210-1, Amsterdam, Netherlands, 1100 DE.
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