Sacral nerve stimulation for faecal incontinence and constipation in adults

Magnetogenetic cell activation using endogenous ferritin

The ability to precisely control the activity of defined cell populations enables studies of their physiological roles and may provide therapeutic applications. While prior studies have shown that magnetic activation of ferritin-tagged ion channels allows cell-specific modulation of cellular activity, the large size of the constructs made the use of adeno-associated virus, AAV, the vector of choice for gene therapy, impractical. In addition, simple means for generating magnetic fields of sufficient strength have been lacking. Toward these ends, we first generated a novel anti-ferritin nanobody that when fused to transient receptor potential cation channel subfamily V member 1, TRPV1, enables direct binding of the channel to endogenous ferritin in mouse and human cells. This smaller construct can be delivered in a single AAV and we validated that it robustly enables magnetically induced cell activation in vitro . In parallel, we developed a simple benchtop electromagnet capable of gating the nanobody-tagged channel in vivo . Finally, we showed that delivering these new constructs by AAV to pancreatic beta cells in combination with the benchtop magnetic field delivery stimulates glucose-stimulated insulin release to improve glucose tolerance in mice in vivo . Together, the novel anti-ferritin nanobody, nanobody-TRPV1 construct and new hardware advance the utility of magnetogenetics in animals and potentially humans.

Outcomes and efficacy of magnetic resonance imaging-compatible sacral nerve stimulator for management of fecal incontinence: A multi-institutional study

BACKGROUND

Fecal incontinence (FI) is an involuntary passage of fecal matter which can have a significant impact on a patient's quality of life. Many modalities of treatment exist for FI. Sacral nerve stimulation is a well-established treatment for FI. Given the increased need of magnetic resonance imaging (MRI) for diagnostics, the InterStim which was previously used in sacral nerve stimulation was limited by MRI incompatibility. Medtronic MRI-compatible InterStim was approved by the United States Food and Drug Administration in August 2020 and has been widely used.

AIM

To evaluate the efficacy, outcomes and complications of the MRI-compatible InterStim.

METHODS

Data of patients who underwent MRI-compatible Medtronic InterStim placement at UPMC Williamsport, University of Minnesota, Advocate Lutheran General Hospital, and University of Wisconsin-Madison was pooled and analyzed. Patient demographics, clinical features, surgical techniques, complications, and outcomes were analyzed. Strengthening the Reporting of Observational studies in Epidemiology(STROBE) cross-sectional reporting guidelines were used.

RESULTS

Seventy-three patients had the InterStim implanted. The mean age was 63.29 ± 12.2 years. Fifty-seven (78.1%) patients were females and forty-two (57.5%) patients had diabetes. In addition to incontinence, overlapping symptoms included diarrhea (23.3%), fecal urgency (58.9%), and urinary incontinence (28.8%). Fifteen (20.5%) patients underwent Peripheral Nerve Evaluation before proceeding to definite implant placement. Thirty-two (43.8%) patients underwent rechargeable InterStim placement. Three (4.1%) patients needed removal of the implant. Migration of the external lead connection was observed in 7 (9.6%) patients after the stage I procedure. The explanation for one patient was due to infection. Seven (9.6%) patients had other complications like nerve pain, hematoma, infection, lead fracture, and bleeding. The mean follow-up was 6.62 ± 3.5 mo. Sixty-eight (93.2%) patients reported significant improvement of symptoms on follow-up evaluation.

CONCLUSION

This study shows promising results with significant symptom improvement, good efficacy and good patient outcomes with low complication rates while using MRI compatible InterStim for FI. Further long-term follow-up and future studies with a larger patient population is recommended.

Diagnostic tools for fecal incontinence: Scoring systems are the crucial first step

The main aim of this editorial is to comment on the recent article published by Garg et al in the World Journal of Gastroenterology 2023; 29: 4593-4603. This original research presents a new scoring system for fecal incontinence. Fecal incontinence is a chronic disease with a severe impact on the quality of life of the patients. Substantial social stigmatization often leads to significant underreporting of the condition even during visits to a specialist and could lead to further mismanagement or non-existent management of the disease. An important fact is that patients are often unable to describe their condition when not asked precisely defined questions. This problem is partially resolved by scoring questionnaires. Several scoring systems are commonly used; however, each of them has their shortcomings. For example, the absence of different kinds of leakage besides flatus and stool could further lead to underscoring the incontinence severity. Therefore, there has long been a call for a more precise scoring system. The correct identification of the presence and severity of fecal incontinence is paramount for further diagnostic approach and for choosing the appropriate therapy option. This editorial describes fecal incontinence, its effect on quality of life in general and further evaluates the diagnostic approach with a particular focus on symptom scoring systems and their implications for clinical practice.

Sacral Neuromodulation for defecation disorders after non oncologic pelvic surgery

PURPOSE

Defecation disorders (DD) can sometimes affect the outcomes of pelvic or colorectal surgery. The aim of the present study is to evaluate the role of sacral neuromodulation for the treatment of constipation and other evacuation disorders after surgery.

METHODS

A retrospective analysis in all the consecutive patients that underwent sacral nerve modulation (SNM) for DD arisen or worsened after pelvic or colorectal surgery was performed from January 2010 to December 2020. DD were defined starting from Rome IV Criteria, and according to manometric results, all patients were further divided into the two subgroups: inadequate defecatory propulsion and dyssynergic defecation. Cleveland Clinic Constipations Score (CCCS) and SF-36 have been evaluated in the time.

RESULTS

Thirty-seven patients have been included in the study. Twenty-seven out of thirty-seven (73.3%) patients had experienced sufficient benefits to implant the definitive device, and 22 patients (59.4% of tested and 81.5% of permanently implanted) still had the device functioning after a mean follow-up of 6.3 years. The most represented manometric pattern was inadequate propulsive function (59% of patients). CCCS at preoperative assessment for all patients was 17.5 with a reduction to 10.4 at the first year of follow-up (p < 0.001).

CONCLUSION

SNM appears to be a feasible, safe, and well-tolerated procedure with durable benefit in the long-term treatment of defecatory dysfunction after pelvic or colorectal surgery for benign diseases.

Electroceuticals for Neurogastroenterology and Motility Disorders

PURPOSE OF REVIEW

To provide an updated overview on use of electrostimulation in gastrointestinal motility disorders and obesity, with a focus on gastric electrical stimulation, vagal nerve stimulation and sacral nerve stimulation.

RECENT FINDINGS

Recent studies on gastric electrical stimulation for chronic vomiting showed a decrease in frequency of vomiting, but without significant improvement in quality of life. Percutaneous vagal nerve stimulation shows some promise for both symptoms of gastroparesis and IBS. Sacral nerve stimulation does not appear effective for constipation. Studies of electroceuticals for treatment of obesity have quite varied results with less clinical penetrance of the technology. Results of studies on the efficacy of electroceuticals have been variable depending on pathology but this area remains promising. Improved mechanistic understanding, technology and more controlled trials will be helpful to establish a clearer role for electrostimulation in treatment of various GI disorders.

Long-term functional results of transvaginal anal sphincter repair for faecal incontinence; a retrospective case series

INTRODUCTION AND HYPOTHESIS

We report our experience with a transvaginal approach with overlapping anal sphincter repair. The aim of this cohort study was to evaluate long-term functional outcomes. Women who had undergone transvaginal anal sphincteroplasty for anal incontinence from July 2005 to July 2020 and attended a multidisciplinary team of urogynaecologists and colorectal surgeons at the Mercy Hospital Perineal clinic were included.

METHODS

One hundred seven women were included in the study with a median follow-up of 57.5 months. We analysed outcomes by comparing patient's St Mark's score difference before and after surgery. Meaningful clinical difference (MID) was set at 5 points; complications and patient demographics were recorded along with a question about whether they would recommend this treatment to a friend.

RESULTS

An improvement was seen in 69.3% of women with a marked improvement in 46.5%. Furthermore, 70% said they would recommend the procedure to a friend, if they were in a similar situation. Wound infection or partial perineal breakdown was reported in 45% of women but did not have a significant impact on outcomes.

CONCLUSION

Transvaginal anal sphincter repair is associated with significant improvements in patients' St. Mark's score. Our data show that the long-term success rate of transvaginal/perineal AS repair may be better than previously reported in the literature with 70% of women satisfied at 57 months. Another benefit of the transvaginal route is the possibility of performing a pelvic floor and perineal repair at the time of surgery.

A rapid priority setting exercise combining existing, emergent evidence with stakeholder knowledge identified broad topic uncertainties

OBJECTIVES

The project aimed to rapidly identify priority topic uncertainties as a first step to identify future systematic review questions of pertinence to key international fecal incontinence (FI) stakeholders (patients, carers, health care professionals, policy makers and voluntary, community, or social enterprise representatives). The paper's aim is to share our methods, experience, and learning with other groups planning to deliver a rapid priority setting exercise.

STUDY DESIGN AND SETTING

An evidence gap map incorporated three evidence streams: emerging evidence identified through horizon scanning; existing evidence identified through systematic searches of bibliographic databases; and FI stakeholder insights collected through an international survey. The evidence gap map was presented during an online workshop with stakeholders, where they shared their expertize to expand, refine, and rank topic uncertainties using ideation techniques, focus group discussions, consensus techniques, and online polling.

RESULTS

The multistep methods used to deliver this priority setting exercise resulted in identification of broad priority topic uncertainties. The methods appear to have high acceptability and engagement with participants but await full evaluation.

CONCLUSION

This project successfully followed robust methodology, building upon frameworks from published priority setting and evidence gap mapping projects while incorporating strong patient and public involvement components.

Injection of aluminum potassium sulfate and tannic acid in the treatment of fecal incontinence: a single-center observational study

PURPOSE

Perianal injection of bulking agents is an attractive treatment option for patients with mild to moderate fecal incontinence (FI). Various bulking agents have been used for injection therapy, but the optimal injection materials and methods are yet to be standardized. This study aimed to evaluate the effects of injection therapy using aluminum potassium sulfate and tannic acid (ALTA) in the management of FI.

METHODS

This study included consecutive patients who underwent ALTA injection therapy for FI at our institution. The procedure was performed with the patient in the jackknife position, under caudal epidural anesthesia. The procedure consisted of a 4-step injection to the 3 main cushions and a multipoint injection to the remaining submucosa of the anal canal.

RESULTS

Seventy-seven patients (mean age, 76 years) were enrolled in the study. The mean Cleveland Clinic incontinence score of 11.9 ± 4.1 at baseline significantly improved to 7.3 ± 5.2 at 3 months following treatment. The mean maximal resting pressure also increased significantly 3 months after the intervention. Postoperative complications were observed in 3 patients (3.9%), and all events were mild. The mean duration of postoperative follow-up was 17.5 months. The cumulative recurrence-free rate at 3 years was 72.4%.

CONCLUSION

ALTA injection for FI is safe, easy to perform, and provides reasonable mid-term outcomes. Moreover, concomitant anorectal diseases that may be contraindicated by other injectable bulking agents could be treated simultaneously. Therefore, ALTA injection is a promising alternative in the absence of other injectable agents.

Electrical neuromodulation therapy for inflammatory bowel disease

Inflammatory bowel disease (IBD) is an inflammatory disease of the gastrointestinal (GI) tract. It has financial and quality of life impact on patients. Although there has been a significant advancement in treatments, a considerable number of patients do not respond to it or have severe side effects. Therapeutic approaches such as electrical neuromodulation are being investigated to provide alternate options. Although bioelectric neuromodulation technology has evolved significantly in the last decade, sacral nerve stimulation (SNS) for fecal incontinence remains the only neuromodulation protocol commonly utilized use for GI disease. For IBD treatment, several electrical neuromodulation techniques have been studied, such as vagus NS, SNS, and tibial NS. Several animal and clinical experiments were conducted to study the effectiveness, with encouraging results. The precise underlying mechanisms of action for electrical neuromodulation are unclear, but this modality appears to be promising. Randomized control trials are required to investigate the efficacy of intrinsic processes. In this review, we will discuss the electrical modulation therapy for the IBD and the data pertaining to it.

Electrophysiological Responses in the Human S3 Nerve During Sacral Neuromodulation for Fecal Incontinence

Intra-operative electrode placement for sacral neuromodulation (SNM) relies on visual observation of motor contractions alone, lacking complete information on neural activation from stimulation. This study aimed to determine whether electrophysiological responses can be recorded directly from the S3 sacral nerve during therapeutic SNM in patients with fecal incontinence, and to characterize such responses in order to better understand the mechanism of action (MOA) and whether stimulation is subject to changes in posture. Eleven patients undergoing SNM were prospectively recruited. A bespoke stimulating and recording system was connected (both intraoperatively and postoperatively) to externalized SNM leads, and electrophysiological responses to monopolar current sweeps on each electrode were recorded and analyzed. The nature and thresholds of muscle contractions (intraoperatively) and patient-reported stimulation perception were recorded. We identified both neural responses (evoked compound action potentials) as well as myoelectric responses (far-field potentials from muscle activation). We identified large myelinated fibers (conduction velocity: 36–60 m/s) in 5/11 patients, correlating with patient-reported stimulation perception, and smaller myelinated fibers (conduction velocity <15 m/s) in 4/11 patients (not associated with any sensation). Myoelectric responses (observed in 7/11 patients) were attributed to pelvic floor and/or anal sphincter contraction. Responses varied with changes in posture. We present the first direct electrophysiological responses recorded from the S3 nerve during ongoing SNM in humans, showing both neural and myoelectric responses. These recordings highlight heterogeneity of neural and myoelectric responses (relevant to understanding MOA of SNM) and confirm that electrode lead position can change with posture.

Management Approach of Pediatric Constipation

Constipation is a common challenge in pediatrics. Abdominal radiographs are frequently taken in the pediatric emergency department for diagnosis despite their inadequate reliability to detect the pathology or the degree of constipation. Misdiagnosis of constipation may cause multiple vague physician visits, deployment of emergency medical services, use of radiation, unnecessary laboratory tests, and even surgical procedures. The primary evidence-based suggestions are based on published guidelines that include management of constipation in children divided into three stages of therapy: (1) disimpaction, (2) maintenance therapy, and (3) behavior modification, and special care should be given to neonates and to children with pre-existing medical problems.

Diagnosis and Treatment of Obstetric Anal Sphincter Injuries: New Evidence and Perspectives

Perineal injury during childbirth is a common event with important morbidity associated in particular with third-and-fourth degree perineal tears (also referred to as obstetric anal sphincter injuries—OASIS). Early diagnosis of these damages is mandatory to define a prompt therapeutic strategy and thus avoid the development of late-onset consequences, such as faecal incontinence. For this purpose, various diagnostic exams can be performed after a thorough clinical examination. The management of OASIS includes several measures and should be individualized according to the timing and features of the clinical presentation.

The role of neuromodulation in chronic functional constipation: a systematic review

BACKGROUND

Chronic functional constipation is a highly prevalent disorder in which, when conservative measures fail to relieve symptoms, surgical interventions are sometimes indicated. In recent years, neuromodulation for the treatment of functional constipation has gained interest but its role and effectiveness are still unclear. The purpose of this review is to provide a systematic overview on the current literature on the different modalities of neurostimulation and their effect on chronic functional constipation in adults as reported in the literature.

METHODS

A search in the literature for articles concerning the effect of different types of neuromodulation on constipation was performed in PubMed using extensive search terms for the different modalities of neuromodulation. Studies and trials were checked for eligibility. For all types of neuromodulation together, 27 articles were included.

RESULTS

17 studies were included on SNM (sacral nerve modulation). Although multiple studies show positive results on the effect of SNM in constipation, double-blind crossover RCT's (randomised controlled trials) showed no significant effect. 3 studies were included for tSNS (transcutaneous sacral nerve stimulation), 2 for PTNS (percutaneous tibial nerve stimulation) and 2 for TTNS (transcutaneous tibial nerve stimulation). Studies and trials on these modalities of neuromodulation reported ambiguous results on statistical significance of the effect. For transcutaneous IFC (interferential current therapy) 2 studies were included, which both reported a statistically significant effect on all outcomes.

CONCLUSION

The beneficial effect of neuromodulation in chronic functional constipation remains questionable. However, neuro-modulation might be worth considering in patients refractory to treatment before turning to more invasive measures. Future research should shed more light on the effects of neuromodulation in constipation.

A technique to reconstruct the anal sphincters following iatrogenic stretching related to a pull-through for Hirschsprung disease

Soiling and fecal incontinence are troubling complications which can occur after a pull-through for Hirschsprung disease. They can usually be improved with proper medical management, but in some cases are the result of an anatomic defect related to overstretching of the sphincters and/or damage of the anal canal. For such patients the treatment of this true fecal incontinence is limited to a structured bowel management program with ante- or retrograde enemas to achieve social continence. Herein we report two such patients with overstretched sphincters and loss of the dentate line after an initial pull-through and describe a sphincter tightening technique to improve bowel control.

Effects of temporary sacral nerve stimulation on gastrointestinal motility and function in patients with chronic refractory slow-transit constipation

BACKGROUND

The efficacy of sacral nerve stimulation (SNS) on patients with chronic refractory slow-transit constipation is controversial and its mechanism of action on gastrointestinal motility and transit is not fully understood. The aim of this study was to document the effects of temporary SNS on the gastrointestinal and biliary tract motility and on gastrointestinal transit in patients with refractory slow-transit constipation.

METHODS

This was a prospective interventional study. Patients with slow-transit chronic constipation, unresponsive to any conservative treatment, were enrolled between January 2013 and December 2018. Patients' quality of life [patient assessment of constipation quality of life (PAC-QOL) questionnaire], constipation scores (Cleveland Clinic Constipation Score) colonic transit time (CTT), orocecal transit time (OCTT), gastric and gallbladder kinetics, together with the assessment of the autonomic nerve function were evaluated before and during temporary SNS.

RESULTS

14 patients (12 females, median age 38 years, range 24-42 years) had temporary SNS. The Cleveland Clinic Constipation Score did not change compared to baseline (23 ± 3 vs 21.4; p = 070). The PAC-QOL did not improve significantly during the stimulation period. Gallbladder/stomach motility (half-emptying time) did not change significantly before and after SNS. OCTT was delayed at baseline, as compared to standard internal normal values, and did not change during SNS. CTT did not improve significantly, although in two patients it decreased substantially from 97 to 53 h, and from 100 to 65 h.

CONCLUSIONS

Temporary SNS did not have any effect on upper/lower gastrointestinal motility and transit in patients with severe constipation.

Fecal Incontinence in the Elderly

Fecal incontinence can be a challenging and stigmatizing disease with a high prevalence in the elderly population. Despite effective treatment options, most patients do not receive care. Clues in the history and physical examination can assist the provider in establishing the diagnosis. Direct inquiry about the presence of incontinence is key. Bowel disturbances are common triggers for symptoms and represent some of the easiest treatment targets. We review the epidemiology and impact of the disease, delineate a diagnostic and treatment approach for primary care physicians to identify patients with suspected fecal incontinence and describe appropriate treatment options.

Translumbosacral Neuromodulation Therapy Is a Promising Option for Fecal Incontinence

ABSTRACT

Fecal incontinence is a common symptom that can significantly impair quality of life. The treatment options range from conservative measures (e.g., Kegel exercises, pelvic floor biofeedback therapy, fiber supplementation, or medications) to noninvasive nerve stimulation (e.g., posterior tibial nerve stimulation and transcutaneous tibial nerve stimulation), implanted neurostimulation (i.e., sacral nerve stimulation), perianal injection of dextranomer, and anal sphincteroplasty. In this issue of the journal, a promising, uncontrolled study suggests that noninvasive, repetitive magnetic stimulation of the lumbosacral nerves significantly improved symptoms, increased anal squeeze pressure, and increased rectal compliance in patients with fecal continence. Sham-controlled studies are necessary to confirm these findings.

Progress in research of sacral nerve stimulation

Sacral nerve stimulation (SNS) is well-known as a minimally invasive treatment. Originally, it was mainly used to treat urinary system diseases such as urge urinary incontinence. Gradually, it is used to treat digestive system diseases such as fecal incontinence and chronic constipation. SNS is a method in which electrical pulse signals are sent out through pulse generators to stimulate the sacral nerve directly or indirectly, thus modulating the nerve reflex of the bladder, urethra, anus, colon, and rectum and improving abnormal nerve regulation to achieve the therapeutic effect. The regulation of the sacral nerve is often carried out by inserting electrodes into the sacral spinal canal S_2-4 (mostly S₃), and the symptoms are improved by complex regulation of spinal reflex and supraspinal reflex. However, the exact mechanism is still unclear. Many studies have shown that SNS plays a key role in the treatment of many diseases of the urinary system and digestive system. This paper reviews the progress in the research of SNS.

Bioelectrical Signals for the Diagnosis and Therapy of Functional Gastrointestinal Disorders

Coordinated contractions and motility patterns unique to each gastrointestinal organ facilitate the digestive process. These motor activities are coordinated by bioelectrical events, sensory and motor nerves, and hormones. The motility problems in the gastrointestinal tract known as functional gastrointestinal disorders (FGIDs) are generally caused by impaired neuromuscular activity and are highly prevalent. Their diagnosis is challenging as symptoms are often vague and difficult to localize. Therefore, the underlying pathophysiological factors remain unknown. However, there is an increasing level of research and clinical evidence suggesting a link between FGIDs and altered bioelectrical activity. In addition, electroceuticals (bioelectrical therapies to treat diseases) have recently gained significant interest. This paper gives an overview of bioelectrical signatures of gastrointestinal organs with normal and/or impaired motility patterns and bioelectrical therapies that have been developed for treating FGIDs. The existing research evidence suggests that bioelectrical activities could potentially help to identify the diverse etiologies of FGIDs and overcome the drawbacks of the current clinically adapted methods. Moreover, electroceuticals could potentially be effective in the treatment of FGIDs and replace the limited existing conventional therapies which often attempt to treat the symptoms rather than the underlying condition.

Comparison of antegrade continence enema treatment and sacral nerve stimulation for children with severe functional constipation and fecal incontinence

BACKGROUND

To compare antegrade continence enema (ACE) treatment and sacral nerve stimulation (SNS) in children with intractable functional constipation (FC) and fecal incontinence (FI).

METHODS

We performed a retrospective review of children 6-18 years old with FC and FI treated with either ACE or SNS at our institution. We recorded symptoms at baseline, 6 months, 12 months, 24 months, and their most recent visit after starting treatment. We compared improvement in FI, bowel movement (BM) frequency, abdominal pain, laxative use, and complications. Patients were contacted to evaluate perceived benefit using the Glasgow Children's Benefit Inventory.

KEY RESULTS

We included 23 patients treated with ACE (52% female, median age 10 years) and 19 patients treated with SNS (74% female, median age 10 years). Improvement in FI was greater with SNS than ACE at 12 months (92.9% vs 57.1%, P = .03) and 24 months (100% vs 57.1%, P = .02). Improvement in BM frequency was greater with ACE, and children were more likely to discontinue laxatives at all follow-up time points (all P < .05). Improvement in abdominal pain was greater with ACE at the most recent visit (P < .05). Rate of complications requiring surgery was similar between groups (26.3% vs 21.7%). Benefit was reported in 83.3% and 100% of ACE and SNS groups, respectively (NS).

CONCLUSIONS AND INFERENCES

Although both ACE and SNS can lead to durable improvement in children with FC and FI, SNS appears more effective for FI and ACE more effective in improving BM frequency and abdominal pain and in discontinuation of laxatives.

[Surgical reconstruction of traumatic sphincter muscle defects]

BACKGROUND

Traumatic anal sphincter muscle defects often occur after childbirth and surgery and can lead to fecal incontinence that requires further treatment.

OBJECTIVE

The aim of this article is to illustrate the etiology of traumatic sphincter muscle defects, the treatment options of subsequent fecal incontinence and their evaluation on the basis of current studies.

MATERIAL AND METHODS

Selected studies are presented.

RESULTS

Fecal incontinence presenting with a traumatic sphincter muscle defect is often due to multiple factors especially in the aged and makes the use of extended diagnostic tools necessary; however, the subjective complaints do not always correlate with morphological or functional diagnostic findings. Besides reconstructive procedures, such as sphincteroplasty and graciloplasty, sphincter augmentation techniques and sacral nerve stimulation can also be applied in traumatic sphincter muscle defects that are often associated with a loss of efficacy in the long term or a high rate of adverse events.

CONCLUSION

The fecal incontinence associated with traumatic sphincter insufficiency represents a diagnostic and therapeutic challenge due to the multifactorial origin. It is not uncommon that patients have to undergo several surgical and conservative interventions.

Anorectal angle at rest predicting successful sacral nerve stimulation in idiopathic fecal incontinence-a cohort analysis

PURPOSE

Sacral nerve stimulation is an effective treatment for patients suffering from fecal incontinence. However, less is known about predictors of success before stimulation. The purpose of this study was to identify predictors of successful sacral nerve stimulation in patients with idiopathic fecal incontinence.

METHODS

Consecutive female patients, receiving peripheral nerve evaluation and sacral nerve stimulation between September 2008 and October 2014, suffering from idiopathic fecal incontinence were included in this study. Preoperative patient's characteristics, anal manometry, and defecography results were collected prospectively and investigated by retrospective analysis. Main outcome measures were independent predictors of treatment success after sacral nerve stimulation.

RESULTS

From, all in all, 54 patients suffering from idiopathic fecal incontinence receiving peripheral nerve evaluation, favorable outcome was achieved in 23 of 30 patients after sacral nerve stimulation (per protocol 76.7%; intention to treat 42.6%). From all analyzed characteristics, wide anorectal angle at rest in preoperative defecography was the only independent predictor of favorable outcome in multivariate analysis (favorable 134.1 ± 13.9° versus unfavorable 118.6 ± 17.1°).

CONCLUSIONS

Anorectal angle at rest in preoperative defecography might present a predictor of outcome after sacral nerve stimulation in patients with idiopathic fecal incontinence.

Sacral nerve stimulation with appropriate parameters improves constipation in rats by enhancing colon motility mediated via the autonomic-cholinergic mechanisms

Although sacral nerve stimulation (SNS) has been applied for treating constipation, its parameters were adopted from SNS for fecal incontinence, its effects are limited, and mechanisms are largely unknown. We investigated the effects and mechanism of SNS with appropriate parameters on constipation in rats treated with loperamide. First, using rectal compliance as an outcome measure, an experiment was performed to derive effective SNS parameters. Then, a 7-day SNS was performed in rats with constipation induced by loperamide. Autonomic functions were assessed by spectral analysis of heart rate variability (HRV) derived from an electrocardiogram. Serum levels of pancreatic polypeptide (PP), norepinephrine (NE), and acetylcholine (ACh) in colon were assessed. 1) Acute SNS at 5 Hz, 100 µs was found effective in enhancing rectal compliance and accelerating distal colon transit (P < 0.05 vs. sham SNS). 2) The 7-day SNS normalized loperamide-induced constipation, assessed by the number, weight, and water content of fecal pellets, and accelerated the distal colon transit (29.4 ± 3.7 min with sham SNS vs. 16.4 ± 5.3 min with SNS but not gastric emptying or intestinal transit. 3) SNS significantly increased vagal activity (P = 0.035) and decreased sympathetic activity (P = 0.012), assessed by spectral analysis of HRV as well as by the serum PP. 4) SNS increased ACh in the colon tissue; atropine blocked the accelerative effect of SNS on distal colon transit. We concluded that SNS with appropriate parameters improves constipation induced by loperamide by accelerating distal colon motility, mediated via the autonomic-cholinergic function.NEW & NOTEWORTHY Although sacral nerve stimulation (SNS) has been applied for treating constipation, its parameters were adopted from SNS for fecal incontinence, effects are limited, and mechanisms are largely unknown. This paper shows that SNS with appropriate parameters improves constipation induced by loperamide by accelerating distal colon motility mediated via the autonomic-cholinergic function.

What Is New in Neuromodulation?

Neuromodulation encompassing sacral and peripheral modalities is an established, effective, and safe higher-order treatment option approved in the USA for managing refractory overactive bladder, non-obstructive urinary retention, and fecal incontinence. This review highlights the most recent literature, indications, treatment durability, and the latest innovations in this field. Regarding sacral neuromodulation (SNM), recent work suggests improved parameters for optimal lead placement, increased data to support the lasting effects of treatment, and novel applications of this technology to other pelvic disorders. In addition, there are emerging technologies with smaller MRI compatible devices. Newer data on percutaneous tibial nerve stimulation (PTNS) suggests it may be more beneficial for certain patients. With new technology, implantable tibial nerve stimulators are ushering in a new frontier of nerve stimulation in the comfort of the patient's home.

Pathophysiology and management of diabetic gastroenteropathy

Polyneuropathy is a common complication to diabetes. Neuropathies within the enteric nervous system are associated with gastroenteropathy and marked symptoms that severely reduce quality of life. Symptoms are pleomorphic but include nausea, vomiting, dysphagia, dyspepsia, pain, bloating, diarrhoea, constipation and faecal incontinence. The aims of this review are fourfold. First, to provide a summary of the pathophysiology underlying diabetic gastroenteropathy. Secondly to give an overview of the diagnostic methods. Thirdly, to provide clinicians with a focussed overview of current and future methods for pharmacological and nonpharmacological treatment modalities. Pharmacological management is categorised according to symptoms arising from the upper or lower gut as well as sensory dysfunctions. Dietary management is central to improvement of symptoms and is discussed in detail, and neuromodulatory treatment modalities and other emerging management strategies for diabetic gastroenteropathy are discussed. Finally, we propose a diagnostic/investigation algorithm that can be used to support multidisciplinary management.

[Sacral neuromodulation in under- and overactive detrusor-quo vadis? : Principles and developments]

BACKGROUND

Sacral neuromodulation (SNM) has been used in the treatment of refractory overactive bladder syndrome, nonobstructive urinary retention and faecal incontinence for almost 40 years now. It is not to be confused with the sacral anterior root stimulation which is exclusively used for bladder dysfunction due to spinal paraplegia.

MECHANISM OF ACTION

The principles of SNM are yet to be fully understood. Nevertheless, there is proof of modulating the activity of several micturition-associated, afferent neurons in the spine, brainstem and cerebrum. Thus, premature detrusor contractions are suppressed, the desire to void is delayed and detrusor-sphincter coordination improves.

TECHNIQUES OF IMPLANTATION AND STIMULATION

Motor reactions are an important indicator of correct electrode placement. The implantation procedure consists of two stages with an initial trial phase to determine the best possible treatment response through an external generator before implanting the whole stimulating device. Yearly check-up examinations are recommended; wireless adjustments allow for long-lasting symptom reduction.

INDICATION AND OUTCOME

Success rates in the treatment of the refractory overactive bladder syndrome and the non-obstructive urinary retention lie above 70% and can still be perceived as sufficient after 5 years of ongoing SNM therapy. There is also profound evidence of SNM being an effective option for patients with faecal incontinence or chronic obstipation.

CONTRAINDICATIONS AND RISKS

Children, pregnant women and patients in need of frequent MRI examinations are usually not eligible for SNM therapy. Infection of the implant, technical failure (including lead displacement and battery depletion) and pain in the implantation site are important adverse effects which might require surgical revision.

CONCLUSIONS

The indications for SNM in the German health care system can be expected to be expanded upon the chronic pelvic pain syndrome, erectile dysfunction and additional gastrointestinal conditions. Technical progress will continue to improve the risk-benefit ratio of SNM.

Controversies in the Management of Functional Constipation in Children

PURPOSE OF REVIEW

Functional constipation (FC) in children is a common health problem with reported worldwide prevalence rates up to 32.2%. The majority of children with constipation respond to oral laxative treatment. After 5 years of intensive treatment, however, approximately 50% of children remain symptomatic. To discuss the evidence for new treatments in these children, including pre- and probiotics, pelvic physiotherapy, prucalopride, sacral nerve stimulation, and surgery, and to highlight the controversies surrounding them.

RECENT FINDINGS

Pre- and probiotics and prucalopride are not effective in the treatment of childhood constipation. Pelvic physiotherapy and sacral nerve stimulation are promising treatment options but larger trials are needed. Surgery for pediatric constipation is the treatment of last resort. Large, well-designed placebo-controlled trials with proper outcome measures, as suggested by the Rome foundation pediatric subcommittee on clinical trials, are necessary to provide more insight regarding the efficacy of new treatments in childhood constipation.

Etiology and management of low anterior resection syndrome based on the normal defecation mechanism

Low anterior resection syndrome (LARS) commonly develops after an anal sphincter-preserving operation (SPO). The etiology of LARS is not well understood, as the anatomical components and physiological function of normal defecation, which may be damaged during the SPO, are not well established. SPOs may damage components of the anal canal (such as the internal anal sphincter, longitudinal conjoint muscle, or hiatal ligament), either mechanically or via injury to the nerves that supply these organs. The function of the rectum is substantially impaired by resection of the rectum, division of the rectococcygeus muscle, and/or injury of the nervous supply. When the remnant rectum is small and does not function properly, an important functional role may be played by the neorectum, which is usually constructed from the left side of the colon. Hypermotility of the remnant colon may affect the manifestation of urge fecal incontinence. To develop an SPO that minimizes the risk of LARS, the anatomy and physiology of the structures involved in normal defecation need to be understood better. LARS is managed similarly to fecal incontinence. In particular, management should focus on reducing colonic motility when urge fecal incontinence is the dominant symptom.

Success and Complication Rates After Sacral Neuromodulation for Fecal Incontinence and Constipation: A Single-center Follow-up Study

Background/Aims

The aim of this study was to evaluate the sustainability of sacral neuromodulation (SNM) success in patients with fecal incontinence (FI) and/or constipation.

Methods

This is a retrospective analysis of a prospective database of patients who received SNM therapy for FI and/or constipation between 2006 and 2015. Success rates, complications and reintervention rates were assessed after up to 10 years of follow-up.

Results

Electrodes for test stimulation were implanted in 101 patients, of whom 79 (78.2%) received permanent stimulation. The mean follow-up was 4.4 ± 3.0 years. At the end of follow-up, 57 patients (72.2%) were still receiving SNM. The 5-year success rate for FI and isolated constipation was 88.2% (95% confidence interval [CI], 80.1-97.0%) and 31.2% (95% CI, 10.2-95.5%), respectively (P ＜ 0.001). In patients with FI, involuntary evacuations per week decreased ＞ 50% in 76.1% of patients (95% CI, 67.6-86.2%) after 5 years. A lead position at S3 was associated with an improved outcome (P = 0.04). Battery exchange was necessary in 23 patients (29.1%), with a median battery life of 6.2 years. Reinterventions due to complications were necessary in 24 patients (30.4%). For these patients, the 5-year success rate was 89.0% (95% CI, 75.3-100.0%) compared to 78.4% (95% CI, 67.2-91.4%) for patients without reintervention.

Conclusions

SNM offers an effective sustainable treatment for FI. For constipation, lasting success of SNM is limited and is thus not recommended. Reinterventions are necessary but do not impede treatment success.

Impact of sphincter lesions and delayed sphincter repair on sacral neuromodulation treatment outcomes for faecal incontinence: results from a Finnish national cohort study

PURPOSE

The aim of this multicentre study was to analyse the effects of patent sphincter lesions and previous sphincter repair on the results of sacral neuromodulation (SNM) treatment on patients with faecal incontinence (FI).

METHODS

Patients examined by endoanal ultrasound (EAUS) with FI as the indication for SNM treatment were included in the study. Data was collected from all the centres providing SNM treatment in Finland and analysed for differences in treatment outcomes.

RESULTS

A total of 237 patients treated for incontinence with SNM had been examined by EAUS. Of these patients, 33 had a history of previous delayed sphincter repair. A patent sphincter lesion was detected by EAUS in 128 patients. The EAUS finding did not influence the SNM test phase outcome (p = 0.129) or the final treatment outcome (p = 0.233). Patient's history of prior sphincter repair did not have a significant effect on the SNM test (p = 0.425) or final treatment outcome (p = 0.442).

CONCLUSIONS

Results of our study indicate that a sphincter lesion or previous sphincter repair has no significant effect on the outcome of SNM treatment. Our data suggests that delayed sphincter repair prior to SNM treatment initiation for FI is not necessary.

Cost-effectiveness of sacral nerve stimulation and percutaneous tibial nerve stimulation for faecal incontinence

BACKGROUND

Subcutaneous sacral nerve stimulation is recommended by the United Kingdom (UK) National Institute for Health and Care Excellence (NICE) as a second-line treatment for patients with faecal incontinence who failed conservative therapy. Sacral nerve stimulation is an invasive procedure associated with complications and reoperations. This study aimed to investigate whether delivering less invasive and less costly percutaneous tibial nerve stimulation prior to sacral nerve stimulation is cost-effective.

METHODS

A decision analytic model was developed to estimate the cost-effectiveness of percutaneous tibial nerve stimulation with subsequent subcutaneous sacral nerve stimulation versus subcutaneous sacral nerve stimulation alone. The model was populated with effectiveness data from systematic reviews and cost data from randomized studies comparing both procedures in a UK National Health Service (NHS) setting.

RESULTS

Offering percutaneous tibial nerve stimulation prior to sacral nerve stimulation (compared with delivering sacral nerve stimulation straight away) was both more effective and less costly in all modeled scenarios. The estimated savings from offering percutaneous tibial nerve stimulation first were £662-£5,697 per patient. The probability of this strategy being cost-effective was around 80% at £20,000-£30,000 per quality-adjusted life-year (QALY).

CONCLUSION

Our analyses suggest that offering patients percutaneous tibial nerve stimulation prior to sacral nerve stimulation can be both cost-effective and cost-saving in the treatment of faecal incontinence.

Efficacy and mechanism of sub-sensory sacral (optimised) neuromodulation in adults with faecal incontinence: study protocol for a randomised controlled trial

Background

Faecal incontinence (FI) is a substantial health problem with a prevalence of approximately 8% in community-dwelling populations. Sacral neuromodulation (SNM) is considered the first-line surgical treatment option in adults with FI in whom conservative therapies have failed. The clinical efficacy of SNM has never been rigorously determined in a trial setting and the underlying mechanism of action remains unclear.

Methods/design

The design encompasses a multicentre, randomised, double-blind crossover trial and cohort follow-up study. Ninety participants will be randomised to one of two groups (SNM/SHAM or SHAM/SNM) in an allocation ratio of 1:1. The main inclusion criteria will be adults aged 18–75 years meeting Rome III and ICI definitions of FI, who have failed non-surgical treatments to the UK standard, who have a minimum of eight FI episodes in a 4-week screening period, and who are clinically suitable for SNM. The primary objective is to estimate the clinical efficacy of sub-sensory SNM vs. SHAM at 32 weeks based on the primary outcome of frequency of FI episodes using a 4-week paper diary, using mixed Poisson regression analysis on the intention-to-treat principle. The study is powered (0.9) to detect a 30% reduction in frequency of FI episodes between sub-sensory SNM and SHAM stimulation over a 32-week crossover period.

Secondary objectives include: measurement of established and new clinical outcomes after 1 year of therapy using new (2017 published) optimised therapy (with standardised SNM-lead placement); validation of new electronic outcome measures (events) and a device to record them, and identification of potential biological effects of SNM on underlying anorectal afferent neuronal pathophysiology (hypothesis: SNM leads to increased frequency of perceived transient anal sphincter relaxations; improved conscious sensation of defaecatory urge and cortical/subcortical changes in afferent responses to anorectal electrical stimulation (main techniques: high-resolution anorectal manometry and magnetoencephalography).

Discussion

This trial will determine clinical effect size for sub-sensory chronic electrical stimulation of the sacral innervation. It will provide experimental evidence of modifiable afferent neurophysiology that may aid future patient selection as well as a basic understanding of the pathophysiology of FI.

Trial registration

International Standard Randomised Controlled Trial Number: ISRCTN98760715. Registered on 15 September 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2689-1) contains supplementary material, which is available to authorized users.

Surgical Management of Idiopathic Constipation in Pediatric Patients

Constipation is a common childhood problem, but an anatomic or physiologic cause is identified in fewer than 5% of children. By definition, idiopathic constipation is a diagnosis of exclusion. Careful clinical evaluation and thoughtful use of imaging and other testing can help exclude specific causes of constipation and guide therapy. Medical management with laxatives is effective for the majority of constipated children. For those patients unresponsive to medications, however, several surgical options can be employed, including anal procedures, antegrade colonic enemas, colorectal resection, and intestinal diversion. Judicious use of these procedures in properly selected patients and based on appropriate preoperative testing can lead to excellent outcomes. This review summarizes the surgical options available for managing refractory constipation in children and provides guidance on how to choose the best procedure for a given patient.

Sacral neuromodulation versus personalized conservative treatment in patients with idiopathic slow-transit constipation: study protocol of the No.2-trial, a multicenter open-label randomized controlled trial and cost-effectiveness analysis

PURPOSE

The evidence regarding the (cost-)effectiveness of sacral neuromodulation (SNM) in patients with therapy-resistant idiopathic slow-transit constipation is of suboptimal quality. The Dutch Ministry of Health, Welfare and Sports has granted conditional reimbursement for SNM treatment. The objective is to assess the effectiveness, cost-effectiveness, and budget impact of SNM compared to personalized conservative treatment (PCT) in patients with idiopathic slow-transit constipation refractory to conservative treatment.

METHODS

This study is an open-label, multicenter randomized controlled trial. Patients aged 14 to 80 with slow-transit constipation, a defecation frequency (DF) < 3 per week and meeting at least one other Rome-IV criterion, are eligible. Patients with obstructed outlet, irritable bowel syndrome, bowel pathology, or rectal prolapse are excluded. Patients are randomized to SNM or PCT. The primary outcome is success at 6 months (DF ≥ 3 a week), requiring a sample size of 64 (α = 0.05, β = 0.80, 30% difference in success). Secondary outcomes are straining, sense of incomplete evacuation, constipation severity, fatigue, constipation specific and generic quality of life, and costs at 6 months. Long-term costs and effectiveness will be estimated by a decision analytic model. The time frame is 57 months, starting October 2016. SNM treatment costs are funded by the Dutch conditional reimbursement program, research costs by Medtronic.

CONCLUSIONS

The results of this trial will be used to make a final decision regarding reimbursement of SNM from the Dutch Health Care Package in this patient group.

TRIAL REGISTRATION

This trial is registered at clinicaltrials.gov , identifier NCT02961582, on 12 October 2016.

Surgical Interventions and the Use of Device-Aided Therapy for the Treatment of Fecal Incontinence and Defecatory Disorders

The purpose of this clinical practice update expert review is to describe the key principles in the use of surgical interventions and device-aided therapy for managing fecal incontinence (FI) and defecatory disorders. The best practices outlined in this review are based on relevant publications, including systematic reviews and expert opinion (when applicable). Best Practice Advice 1: A stepwise approach should be followed for management of FI. Conservative therapies (diet, fluids, techniques to improve evacuation, a bowel training program, management of diarrhea and constipation with diet and medications if necessary) will benefit approximately 25% of patients and should be tried first. Best Practice Advice 2: Pelvic floor retraining with biofeedback therapy is recommended for patients with FI who do not respond to the conservative measures indicated above. Best Practice Advice 3: Perianal bulking agents such as intra-anal injection of dextranomer may be considered when conservative measures and biofeedback therapy fail. Best Practice Advice 4: Sacral nerve stimulation should be considered for patients with moderate or severe FI in whom symptoms have not responded after a 3-month or longer trial of conservative measures and biofeedback therapy and who do not have contraindications to these procedures. Best Practice Advice 5: Until further evidence is available, percutaneous tibial nerve stimulation should not be used for managing FI in clinical practice. Best Practice Advice 6: Barrier devices should be offered to patients who have failed conservative or surgical therapy, or in those who have failed conservative therapy who do not want or are not eligible for more invasive interventions. Best Practice Advice 7: Anal sphincter repair (sphincteroplasty) should be considered in postpartum women with FI and in patients with recent sphincter injuries. In patients who present later with symptoms of FI unresponsive to conservative and biofeedback therapy and evidence of sphincter damage, sphincteroplasty may be considered when perianal bulking injection and sacral nerve stimulation are not available or have proven unsuccessful. Best Practice Advice 8: The artificial anal sphincter, dynamic graciloplasty, may be considered for patients with medically refractory severe FI who have failed treatment or are not candidates for barrier devices, sacral nerve stimulation, perianal bulking injection, sphincteroplasty and a colostomy. Best Practice Advice 9: Major anatomic defects (eg, rectovaginal fistula, full-thickness rectal prolapse, fistula in ano, or cloaca-like deformity) should be rectified with surgery. Best Practice Advice 10: A colostomy should be considered in patients with severe FI who have failed conservative treatment and have failed or are not candidates for barrier devices, minimally invasive surgical interventions, and sphincteroplasty. Best Practice Advice 11: A magnetic anal sphincter device may be considered for patients with medically refractory severe FI who have failed or are not candidates for barrier devices, perianal bulking injection, sacral nerve stimulation, sphincteroplasty, or a colostomy. Data regarding efficacy are limited and 40% of patients had moderate or severe complications. Best Practice Advice 12: For defecatory disorders, biofeedback therapy is the treatment of choice. Best Practice Advice 13: Based on limited evidence, sacral nerve stimulation should not be used for managing defecatory disorders in clinical practice. Best Practice Advice 14: Anterograde colonic enemas are not effective in the long term for management of defecatory disorders. Best Practice Advice 15: The stapled transanal rectal resection and related procedures should not be routinely performed for correction of structural abnormalities in patients with defecatory disorders.

Electrophysiological Basis of Fecal Incontinence and Its Implications for Treatment

The majority of patients with neuropathic incontinence and other pelvic floor conditions associated with straining at stool have damage to the pudendal nerves distal to the ischial spine. Sacral nerve stimulation appears to be a promising innovation and has been widely adopted and currently considered the standard of care for adults with moderate to severe fecal incontinence and following failed sphincter repair. From a decision-to-treat perspective, the short-term efficacy is good (70%-80%), but the long-term efficacy of sacral nerve stimulation is around 50%. Newer electrophysiological tests and improved anal endosonography would more effectively guide clinical decision making.

Sacral neuromodulation for faecal incontinence - 10 years' experience at a Scottish tertiary centre

INTRODUCTION

Sacral nerve stimulation (SNS) is increasingly popular in the management of faecal incontinence. This paper reports the first 10-year experience of SNS in the management of faecal incontinence at a tertiary referral centre. Data was collected in a prospectively maintained database.

RESULTS

In total 130 patients were referred. The majority were women (94%) under 75-year-old (98%). Seven patients were found to have full-thickness rectal prolapse at the initial work-up and proceeded to rectopexy. Eighty-three patients underwent temporary SNS testing with 73.5% positive outcome, of which 52 patients had permanent implant insertion. There were four failures of SNS (7%) following implantation despite successful temporary testing, seven infection, one lead migration and three post-operative pain/numbness. One patient subsequently developed colorectal cancer requiring SNS removal. A higher frequency of episodes of incontinence was associated with positive SNS outcome (p = 0.007). There was no significant association between age, sex, type of faecal incontinence, previous anorectal/pelvic surgery, colonoscopic or USS findings and the likelihood of successful SNS. Of the 52 patients with SNS implants, 27 patients were seen only once for follow-up; the remaining 25 patients were seen more than once - five of these were part of our initial cases of routine 6- and 12-monthly follow-up, 6 patients were seen for adjustment of voltages, whereas the remaining 14 patients were seen for complications of the implants. If the initial five patients were excluded, only 38% of patients would have been seen more frequently on an as-required basis.

CONCLUSION

SNS is a safe and effective option in the management of faecal incontinence. Of the initial work-up, endoscopy and examination-under-anaesthesia (EUA) or proctogram are essential and more likely to influence the likelihood of suitability of SNS testing. A patient-led drop-in approach to follow-up is feasible to allow patients to be seen on an as-required basis.

Genetics-based manipulation of adipose tissue sympathetic innervation

There is renewed interest in leveraging the thermogenic capacity of brown adipose tissue (BAT) and browning of white adipose tissue (WAT) to improve energy balance and prevent obesity. In addition to these effects on energy expenditure, both BAT and WAT secrete large numbers of hormones and cytokines that play important roles in maintaining metabolic health. Both BAT and WAT are densely innervated by the sympathetic nervous system (SNS) and this innervation is crucial for BAT thermogenesis and WAT browning, making it a potentially interesting target for manipulating energy balance and treatment of obesity and metabolic disease. Peripheral neuromodulation in the form of electrical manipulation of the SNS and parasympathetic nervous system (PSNS) has been used for the management of pain and many other conditions, but progress is hampered by lack of detailed knowledge of function-specific neurons and nerves innervating particular organs and tissues. Therefore, the goal of the National Institutes of Health (NIH) Common Fund project "Stimulating Peripheral Activity to Relieve Conditions (SPARC)" is to comprehensively map both anatomical and neurochemical aspects of the peripheral nervous system in animal model systems to ultimately guide optimal neuromodulation strategies in humans. Compared to electrical manipulation, neuron-specific opto- and chemogenetic manipulation, now being extensively used to decode the function of brain circuits, will further increase the functional specificity of peripheral neuromodulation.

Intractable Constipation in the Elderly

OPINION STATEMENT

Chronic constipation is a common gastrointestinal disorder disproportionately affecting the elderly. Immobility, polypharmacy, and physiologic changes contribute to its increased prevalence in this population. Unidentified and undertreated constipation leads to a significant negative impact on quality of life and an increase in healthcare spending. Careful physical examination and exploration of the clinical history can unmask primary and secondary forms of constipation, guiding diagnostic and therapeutic considerations. Non-pharmacologic treatment options include bowel training and biofeedback as well as the addition of fiber. Laxatives are safe and can be used long term; thus, they remain the mainstay of therapy. Newer agents with specific physiologic targets have proven to be effective in adults with chronic constipation, but data is lacking for safety profile in the elderly. Consideration for surgery in medically refractory cases should be entertained, while use of neuromodulation is not ready for prime time. This is a review of the currently available treatment options for chronic constipation in adults and specifically tailored towards the elderly.