Systematic review of the prevalence of faecal incontinence

The impact of anal incontinence: psychosocial and sexual consequences and factors associated with QoL in a Norwegian outpatient population

OBJECTIVES

Anal incontinence (AI) is a distressing condition with grave impact on many aspects of life, including quality of life (QoL), social life and sexual activities. This study explored how AI and bowel symptoms impact QoL in a Norwegian population by (1) describing the psychosocial and sexual consequences of AI, and (2) investigating factors most often associated with AI-specific QoL.

MATERIALS AND METHODS

A cross-sectional study among patients with AI referred to hospital outpatient clinics was conducted. A Norwegian version of ICIQ-B was used to measure bowel control, bowel symptoms, sexual impact, and impact on QoL.

RESULTS

A total of 208 persons with AI completed the questionnaire. The results demonstrated that these patients are overall embarrassed, make plans according to the bowels, ensure the presence of a nearby toilet, and many abstain from sexual activities. After adjusting for other variables included in a multivariable model, we found that having bowel accidents on one's mind had the greatest relative impact on QoL, followed by lower bowel control, using more medications to stop bowels, having more pain/soreness around the back passage, lower age, and more straining to open the bowels.

CONCLUSIONS

AI has substantial consequences for the psychosocial function and sexual activities of persons with AI. This study indicates that worrying about potential faecal accidents and the social stigma associated with this have greater impact on QoL than actual bowel leakages. Future studies should therefore focus on the emotional burden, patient coping, and health education related to bowel function and AI.

Urgency an important factor when assessing fecal incontinence

The aim of this study was to investigate if Low Anterior Resection Syndrome (LARS) score contributed with complementary information to Wexner score when assessing fecal incontinence (FI). The hypothesis was that LARS score would be likely to provide complementary information to Wexner score in the assessment of FI regardless of etiology. LARS score has been used as a complement to traditional scoring systems to assess bowel dysfunction, targeting FI among patients after radical cystectomy, in women with endometriosis, and in colorectal cancer patients. Wexner score as a single tool does not address the complexity of FI and urgency, a disabling symptom. A retrospective cohort study at a surgical outpatient clinic included patients diagnosed with FI who answered LARS and Wexner scores questionnaires at their first visit to the clinic between 1st January 2015 and 31st December 2018. Kendall's tau, Spearman rank correlation, Cohen's kappa, and scatterplots were analyzed for participants and specific subgroups to assess any correlation and agreement between answers to the two scoring systems. One hundred nineteen patients met the inclusion criteria, one hundred eight women and eleven men. Kendall's tau ranged from 0.32 to 0.39, indicating lack of correlation. Correlation coefficients using Spearman rank ranged from 0.36 to 0.55, i.e., only fair to moderate correlation. Kappa was 0.21-0.28, i.e., only slight to fair agreement. Distribution of LARS and Wexner scores in the scatterplot showed wide variability and lack of agreement. Combined use of both the Wexner and LARS scores provided complimentary information, and thus a more complete mapping of FI as well as taking all entities in consideration.

GP's role in supporting women with anal incontinence after childbirth injury: a qualitative study

BACKGROUND

Obstetric anal sphincter injury is the most common cause of anal incontinence for women, which often has profound impacts on women's lives. GPs offer a first line of contact for many women, but we know that very few women experiencing anal incontinence postnatally report discussing it with their GPs.

AIM

To identify key ways in which GPs can support women with anal incontinence caused by childbirth injuries.

DESIGN AND SETTING

A qualitative study investigating women's experiences with their GP, and GPs' perspectives about providing such care.

METHOD

This qualitative study combined two phases: first, a series of in-depth semi-structured interviews with women experiencing anal incontinence caused by childbirth injuries (n = 41); and second, focus groups with GPs (n = 13) stratified by experience. Thematic analysis was conducted and relevant themes from across the two datasets were examined.

RESULTS

Mediating factors in GP care for women with anal incontinence caused by childbirth injuries centred around three key themes: the role of the GP, access and pathways, and communication.

CONCLUSION

The findings demonstrate multifactorial challenges in identifying the problem and supporting women experiencing anal incontinence after childbirth injury in primary care settings. Many GPs lacked confidence in their role in supporting women, and women were often reluctant to seek help. Those women who did seek help often experienced frustrations consulting with their GPs. In a context where women are often reluctant to ask for help, their concerns are not always taken seriously, and where GPs do not routinely ask about anal incontinence, potential anal incontinence after childbirth injury appears to be often missed in a primary care setting.

Risk factors for complications following sacral neuromodulation for faecal incontinence: Long-term follow-up

AIM

Sacral neuromodulation (SNM) has become a standard surgical treatment for faecal incontinence (FI). Prior studies have reported various adverse events of SNM, including suboptimal therapeutic response, infection, pain, haematoma, and potential need for redo SNM. The aim of this study was to identify the risk factors associated with long-term complications of SNM.

METHOD

This retrospective cohort reviewed patients who underwent two-stage SNM for FI at our institution between 2011-2021. Preoperative baseline characteristics and follow-up were obtained from the medical record and/or by telephone interview. Management and outcome of each postoperative event were evaluated by univariate and multivariate regression analyses.

RESULTS

A total of 291 patients (85.2% female) were included in this study. Postoperative complications were recorded in 219 (75.2%) patients and 154 (52.9%) patients required surgical intervention to treat complications. The most common postoperative event was loss of efficacy (46.4%). Other common adverse events were problems at the implant site (pain, infection, etc.) in 16.5% and pain during stimulation in 11.7%. Previous vaginal delivery (OR 2.74, p = 0.003) and anal surgery (OR = 2.46, p = 0.039) were independent predictors for complications. Previous colorectal (OR = 2.04, p = 0.026) and anal (OR = 1.98, p = 0.022) surgery and history of irritable bowel syndrome (IBS) (OR = 3.49, p = 0.003) were independent predictors for loss of efficacy.

CONCLUSION

Postoperative adverse events are frequently recorded after SNM. Loss of efficacy is the most common. Previous colorectal or anal surgery, vaginal delivery, and IBS are independent risk factors for complications.

Global Prevalence of Fecal Incontinence in Community-Dwelling Adults: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

Fecal incontinence (FI) can considerably impair quality of life. Through a systematic review and meta-analysis, we sought to determine the global prevalence and geographic distribution of FI and to characterize its relationship with sex and age.

METHODS

We searched PubMed, Web of Science, and Cochrane Library databases to identify population-based surveys of the prevalence of FI.

RESULTS

Of the 5175 articles identified, the final analysis included 80 studies; the median response rate was 66% (interquartile range [IQR], 54%-74%). Among 548,316 individuals, the pooled global prevalence of FI was 8.0% (95% confidence interval [CI], 6.8%-9.2%); by Rome criteria, it was 5.4% (95% CI, 3.1%-7.7%). FI prevalence was greater for persons aged 60 years and older (9.3%; 95% CI, 6.6%-12.0%) compared with younger persons (4.9%; 95% CI, 2.9%-6.9%) (odds ratio [OR], 1.75; 95% CI, 1.39-2.20), and it was more prevalent among women (9.1%; 95% CI, 7.6%-10.6%) than men (7.4%; 95% CI, 6.0%-8.8%]) (OR, 1.17; 95% CI, 1.06-1.28). The prevalence was highest in Australia and Oceania, followed by North America, Asia, and Europe, but prevalence could not be estimated in Africa and the Middle East. The risk of bias was low, moderate, and high for 19 (24%), 46 (57%), and 15 (19%) studies, respectively. Exclusion of studies with high risk of bias did not affect the prevalence of FI or heterogeneity. In the meta-regression, the high study heterogeneity (I2 = 99.61%) was partly explained by age.

CONCLUSIONS

Approximately 1 in 12 adults worldwide have FI. The prevalence is greater among women and older people.

Non-ablative Erbium (YAG) and Neodymium (YAG) Laser Treatment for Anal Incontinence and Vaginal Atrophy: A Case Study

In this case study, a 68-year-old woman with anal incontinence (AI) and vaginal atrophy (VVA), who did not respond to traditional treatments such as pelvic floor exercises or hormone therapy, underwent three sessions of laser treatment using RenovaLase (SP Dynamis; Fotona d.o.o., Ljubljana, Slovenia), which employs non-ablative Erbium:YAG and Neodymium:YAG lasers. Significant improvements were observed in the VVA symptoms, with AI being resolved. The Vaginal Health Index Score increased from 7 points at the initial assessment to 18 points at 12 months after treatment. Similarly, the Cleveland Clinic Florida Fecal Incontinence Score and St. Mark's Incontinence Score, initially at 4 points each, improved to 0 points, indicating resolution of incontinence symptoms. MRI results demonstrated vascular enhancement and growth in the anal sphincter, with the thickness of the internal anal sphincter slightly increasing from initial measurements to a maximum of 0.36 cm, and improvements in resting and squeeze pressures from 42 mmHg to 110 mmHg, respectively. These findings underscore the effectiveness of RenovaLase® laser treatment for VVA and AI symptoms, offering a novel option for pelvic floor health management in postmenopausal women, especially those resistant to the use of artificial devices for anal improvement. In the environment of hormonal decline after menopause, the atrophy of pelvic vessels leads to reduced blood flow. This situation, where a noticeable lack of blood flow occurs during pretreatment of the pelvic vessels, is addressed by laser treatment. This phenomenon has been named "re-canalization." This case suggests the potential of this therapy as an alternative for patients resistant to conventional methods involving the insertion of devices into the anus to improve fecal incontinence. Further research is needed to explore its potential benefits.

Anal incontinence after obstetrical anal sphincter injury significantly impacts quality of life for women: a cohort study

PURPOSE

To assess the prevalence of anal incontinence (AI) after obstetrical anal sphincter injuries (OASIS) and its severity, as well as the risk factors for AI and AI episodes ≥ 6 months.

METHODS

This prospective and observational monocentric cohort study included all the women who had an OASIS between 1 January 2005 and 31 December 2019. Information was collected by using a letter informing for the fecal incontinence quality of life (FIQL) questionnaire and by a phone interview. The main outcome measure was "1 passed or ongoing episode of AI".

RESULTS

Among the 227 patients included, 19.8% had ongoing AI, and 35.2% had AI passed or ongoing episodes. A total of 46.7% of women with AI reported a change in their quality of life in all fields of the FIQL. Excluding a history of inflammatory bowel disease, no factor was associated with the incidence of an AI episode. Post-obstetrical AI ≥ 6 months (POAI ≥ 6) represented 63.7% of AI cases. This incontinence began with significant incidence in the immediate postpartum period but increased over time, unlike AI < 6 months, which appeared primarily in the immediate postpartum period. Instrumental birth was a protective factor for POAI ≥ 6 (OR = 0.24; CI 95% [0.08-0.78]; p = 0.016), while an increase in parity and BMI were risk factors for POAI ≥ 6 (OR = 4.21; CI 95% [1.01-17.71]; p = 0.05 and OR = 1.15; CI 95% [1.03-1.30]; p = 0.016, respectively).

CONCLUSION

The prevalence of AI after OASIS is not underestimated. Despite the fact that women do not seek care, the impact of AI on the quality of life is significant. A case of AI that lasts for 6 months after giving birth risks becoming chronic. Therefore, specialist advice should be recommended in this case.

CLINICAL TRIAL REGISTRY

NCT04940494.

Long-term outcome after SphinKeeper® surgery for treating fecal incontinence-who are good candidates?

PURPOSE

The efficacy of the novel SphinKeeper® procedure for the treatment of fecal incontinence (FI) is not yet well defined. This study aimed to assess long-term functional outcomes after SphinKeeper® surgery.

METHODS

We included 32 patients with FI (28 female), who were operated at a tertiary referral center between August 2018 and September 2021. Functional outcome and quality of life were evaluated prospectively using validated questionnaires before and after surgery. Additionally, endoanal ultrasound and anal manometry were conducted prior and after SphinKeeper® implantation. Predictive parameters for treatment success were defined.

RESULTS

The mean follow-up time was 22.62 ± 8.82 months. The St. Mark's incontinence score decreased significantly after surgery (median preoperative = 19 (IQR 17-22) versus median last follow-up = 12 (IQR 8-16), p = 0.001). Similarly, physical short-form health survey showed a significant improvement after SphinKeeper® implantation (p = 0.011). Patients with a higher degree of internal sphincter defect showed an improved objective therapy success (r = 0.633, p = 0.015) after SphinKeeper® operation, whereas the type and severity of FI had no impact on the functional outcome. Notably, a higher number of dislocated prostheses (r = 0.772, p = 0.015) showed a significant correlation with reduced improvement of incontinence.

CONCLUSION

The SphinKeeper® procedure showed a significant long-term functional improvement in over half of the patients. Patients with a higher internal sphincter defect benefited most, whereas dislocation of the prostheses was associated with less favorable results.

Safety and Efficacy of Iltamiocel Cellular Therapy for the Treatment of Fecal Incontinence. Results of a Phase 1/2 Study

OBJECTIVE

To examine the safety and efficacy of iltamiocel, an investigational cellular therapy of autologous muscle-derived cells, as a treatment for fecal incontinence (FI) in adults.

BACKGROUND

Limited therapeutic options are available for patients with FI refractory to conservative treatments. Cell therapy using autologous muscle-derived cells represents a promising, minimally invasive approach for restoring anal sphincter function.

METHODS

In this multicenter, prospective, non-randomized study, 48 participants were treated with a single iltamiocel dose of 250×10 6 cells. The primary outcome was the incidence of product or procedure-related adverse events (AEs) and serious AEs. Secondary outcomes were changes in the number of FI episodes, Cleveland Clinic Incontinence Score, Fecal Incontinence Quality of Life, and anorectal manometry at 3, 6, and 12 months compared to baseline.

RESULTS

No serious AEs and only one product-related AE of inflammation at the injection site were reported. At 12 months, there was a reduction in median FI episodes (-6.0; 95% confidence interval (CI): -10.0, -1.0) and days with episodes (-4.0; 95% CI: -8.0, -1.0). A ≥50% reduction in FI episodes was observed in 53.7% of participants, and 24.4% had complete restoration of continence. Symptom severity and quality of life improved with mean Cleveland Clinic Incontinence Score reduction (-2.9; 95% CI: -3.7, -2.1), and Fecal Incontinence Quality of Life increased (2.2; 95% CI:1.4, 2.9). No significant changes were detected in anorectal manometry measurements. A history of episiotomy was significantly associated with treatment response in multivariate analysis.

CONCLUSION

The administration of iltamiocel cellular therapy is safe. Iltamiocel shows promise for significantly improving fecal incontinence symptoms and quality of life.

Clinical utility of trans-sacral magnetic stimulation-evoked sphincter potentials and high-density electromyography in pelvic floor assessment: Technical evaluation

AIM

Faecal incontinence is common and of multifactorial aetiologies, yet current diagnostic tools are unable to assess nerve and sphincter function objectively. We developed an anorectal high-density electromyography (HD-EMG) probe to evaluate motor-evoked potentials induced via trans-sacral magnetic stimulation (TSMS).

METHOD

Anorectal probes with an 8 × 8 array of electrodes spaced 1 cm apart were developed for recording HD-EMG of the external anal sphincter. These HD-EMG probes were used to map MEP amplitudes and latencies evoked via TSMS delivered through the Magstim Rapid2 (MagStim Company). Patients undergoing pelvic floor investigations were recruited for this IDEAL Stage 2a pilot study.

RESULTS

Eight participants (median age 49 years; five female) were recruited. Methodological viability, safety and diagnostic workflow were established. The test was well tolerated with median discomfort scores ≤2.5/10, median pain scores ≤1/10 and no adverse events. Higher Faecal Incontinence Severity Index scores correlated with longer MEP latencies (r = 0.58, p < 0.001) and lower MEP amplitudes (r = -0.32, p = 0.046), as did St. Mark's Incontinence Scores with both MEP latencies (r = 0.49, p = 0.001) and MEP amplitudes (r = -0.47, p = 0.002).

CONCLUSION

This HD-EMG probe in conjunction with TSMS presents a novel diagnostic tool for anorectal function assessment. Spatiotemporal assessment of magnetically stimulated MEPs correlated well with symptoms and offers a feasible, safe and patient-tolerable method of evaluating pudendal nerve and external anal sphincter function. Further clinical development and evaluation of these techniques is justified.

Evaluating the risk factors for the development of benign disorders of defaecation: a surgical perspective

PURPOSE

There remains uncertainty as to which risk factors are important for the development of defaecatory problems as a result of heterogeneity of published evidence. Understanding the impact of risk factors may be important in selecting targets for disease prevention or reversal. The aim of this study was to identify and evaluate risk factors for faecal incontinence and chronic constipation.

METHODS

Risk factors for chronic constipation and faecal incontinence were long-listed from scientific literature, then anonymously evaluated (by 50 predominantly colorectal surgical experts from the UK Pelvic Floor Society) using a Delphi technique. Each risk factor was rated as independent, a co-factor, or not a risk factor. Independent risk factors were rated between 1 (not important) and 10 (critically important) with mean (± standard deviation) calculated.

RESULTS

Thirty-eight risk factors for chronic constipation were evaluated. Eighteen were classed as independent and 16 as co-factors. Opioid analgesia (7.87 ± 2.05), eating disorders (7.80 ± 1.72), and history of abuse (7.70 ± 1.89) were scored as most important independent risk factors. Female sex (6.60 ± 2.02) was considered an independent risk factor but increasing age was rated a co-factor. Thirty-three risk factors for faecal incontinence were evaluated. Twenty were classed as independent and eight as co-factors. Third- or fourth-degree tear (8.88 ± 1.57), instrumental delivery (8.47 ± 1.58), and grand multiparity (8.00 ± 1.63) were rated most important. Increasing age (7.41 ± 2.14) and female sex (7.58 ± 2.05) were both considered independent risk factors.

CONCLUSIONS

Several risk factors for chronic constipation and faecal incontinence were selected by Delphi approach. These factors will feed forward into Bayesian models of disease prediction that combine data and expert knowledge.

Research on biomechanical compatibility for a novel artificial anal sphincter with constant force

BACKGROUND

Existing artificial anal sphincter studies have shown that biomechanical compatibility problem between artificial anal sphincter and rectum caused by long-term morphological changes of the tissue surrounding the implanted prosthesis can lead to device failure or tissue ischemic necrosis. In this article, a mechanical artificial anal sphincter with constant force clamping is designed based on the superelasticity of shape memory alloys, which improved the biomechanical compatibility of implantable artificial anal sphincter.

METHODS

Firstly, the anatomical structure and the biomechanical properties of the rectum are analyzed to obtain the size parameters and material parameters of the rectal model. Secondly, a novel artificial anal sphincter with constant force is designed to improve the biomechanical compatibility between the artificial sphincter and the rectum. Thirdly, the static analysis of artificial anal sphincter is carried out by finite element analysis.

RESULTS

The simulation results show that the artificial anal sphincter can maintain a constant clamping force of 4 N within a certain variation range of intestinal tissue thickness, which verifies the constant force characteristic of the artificial anal sphincter. The constant clamping force of the artificial anal sphincter to the rectum is 4 N that is greater than the clamping force 3.99 N required to close the rectum, which verifies the effectiveness the artificial anal sphincter. The surface contact stress and the minimum principal stress of the rectum in the clamping state are less than the pressure threshold, which verifies the safety of the artificial anal sphincter.

CONCLUSIONS

The novel artificial anal sphincter has better biomechanical compatibility and improves the mechanical match between artificial sphincter and intestinal tissue. This study may provide more reasonable and effective simulation data for in vivo experiments of artificial anal sphincter in future, which may provide theoretical and technical support for further research about clinical application of artificial anal sphincter.

Development of toileting behaviour evaluation for Japanese older patients using wheelchairs in a hospital setting: a validation study

BACKGROUND

Ageing limits the activities of daily living (ADLs). Among ADLs, a lack of toileting independence causes a decline in the quality of life, mental health, and social participation. Therefore, occupational therapists spend considerable time assessing toileting disability based on various assessment methods for toileting behaviour. However, these assessment methods have issues with the grading levels, number of items, and diseases covered, and they fail to evaluate toileting behaviour accurately and sensitively. Hence, this study developed a Toileting Behaviour Evaluation (TBE) on a 6-point ordinal scale for patients using wheelchairs, with 22 activity components for various diseases.

METHODS

This study examined the reliability and validity of the TBE in acute and subacute hospitals in Japan. To this end, two occupational therapists assessed 50 patients for inter-rater reliability at different times and one assessed them twice within 7-10 days for intra-rater reliability using the TBE. Furthermore, occupational therapists assessed 100 patients for internal consistency using the TBE and for concurrent validity using the TBE and Functional Independence Measure (FIM). The patients had been diagnosed with various diseases. This study used the weighted kappa coefficient for statistical analysis of the inter-rater and intra-rater reliability, Cronbach's alpha coefficient for internal consistency, and Spearman's rank correlation coefficient for concurrent validity. We performed all statistical analyses using the IBM SPSS Statistics ver. 25 for Windows. All P-values < 0.05 were considered statistically significant.

RESULTS

The minimum weighted kappa coefficients for the inter-rater and intra-rater reliability for each item were 0.67 and 0.79, respectively. Cronbach's alpha was 0.98 for the 22 items. The Spearman's rank correlation coefficient between the mean scores on the TBE and FIM for toilet-related items was 0.74 (P < .01).

CONCLUSIONS

The TBE demonstrated good reliability and validity. This means that therapists can use it to identify impaired toileting behaviour. However, the relationship between impairments and each item of toileting behaviour should be explored in future studies. Additionally, studies should examine the creation of a specific index of functions of independence in each toileting behaviour.

Association between toileting and falls in older adults admitted to the emergency department and hospitalised: a cross-sectional study

OBJECTIVES

This study aimed to explore the potential risk factors associated with toileting-related falls in community-dwelling older adults who presented to the emergency department and were subsequently hospitalised.

DESIGN

This was a cross-sectional study.

SETTING AND PARTICIPANTS

This study was conducted in two teaching hospitals in Shanghai, China between October 2019 and December 2021 among community-dwelling adults aged ≥60 years.

METHODS

In-person interviews, physical assessment and medical record review were performed to collect data on the characteristics and risk factors of falls. Associations of toileting-related falls with demographic characteristics and geriatric syndromes were examined using logistic regression models.

MAIN OUTCOME MEASURES

Potential risk factors for toileting-related falls.

RESULTS

This study included 419 older patients with a mean age of 73.8±9.7 years. Among 60 (14.3%) patients with toileting-related falls (mean age: 78.8±9.2 years), 63.3% of toileting-related falls, mainly occurred between 00:00 and 05:59 hours, compared with 17.3% of non-toileting-related falls, which primarily occurred during the daytime. The rate of recurrent falls (35%) was significantly higher in the toileting-related falls group than in the non-toileting-related falls group (21.2%) (p=0.02). Logistic regression showed that visual impairment (OR 2.7, 95% CI 1.1 to 7.1), cognitive impairment (OR 3.3, 95% CI 1.3 to 8.4), gait instability (OR 3.1, 95% CI 1.1 to 8.8) and urinary incontinence (OR 3.4, 95% CI 1.2 to 9.9) were strongly associated with toileting-related falls. Twenty-three (38.3%) patients in the toileting-related falls group had moderate and severe injuries, compared with 71.7% in the non-toileting-related falls group (p<0.05).

CONCLUSIONS

This study revealed that patients who reported toileting-related falls were more likely to have cognitive impairment, urinary incontinence, gait instability, visual impairment than patients who fell during other activities. Social and healthcare professionals should prioritise the management of toileting activities in older patients and provide targeted interventions to those in the high-risk group.

Young women and elderly men at risk of severe faecal incontinence: results of a French nationwide database analysis : Faecal incontinence in France

PURPOSE

The incidence of severe faecal incontinence (FI) in young people is likely underestimated. The objective of this study is to assess the incidence of FI by using the French national insurance information system (SNDS).

METHODS

The SNDS was used, including 2 health insurance claims databases. The study included 49,097,454 French people who were ≥ 20 years old in 2019. The main outcome measure was the occurrence of FI.

RESULTS

In 2019, 123,630 patients out of the entire French population (n = 49 097 454) (0.25%) were treated for FI. The numbers of male and female patients were similar. The data showed a dramatic increase in the incidence of FI between the ages of 20 and 59 in female patients, compared to 60 and 79 in male patients. The risk of FI increased with age (OR of 3.6 to 11.3 depending on age). Women had a higher risk of severe FI compared to men between the ages of 20 and 39 (OR = 1.3; 95%CI:1.3-1.4) and the ages of 40 and 59 (OR = 1.1; 95%CI:1.08-1.13). This risk decreased after the age of 80 (OR = 0.96; 95%CI:0.93-0.99). The rate of diagnosis of FI also increased where there were greater numbers of proctologists practising in the region of residence in question (OR of 1.07 to 1.35 depending on the number of proctologists).

CONCLUSION

Young women who have given birth and elderly men are at risk of FI and must be targeted by public health information campaigns. The development of coloproctology networks should be encouraged.

Supported Intervention Versus Intervention Alone for Management of Fecal Incontinence in Patients With Inflammatory Bowel Disease: A Multicenter Mixed-Methods Randomized Controlled Trial

PURPOSE

The aims of this study were to test a noninvasive self-management intervention supported by specialist nurses versus intervention alone in patients with inflammatory bowel disease (IBD) experiencing fecal incontinence and to conduct a qualitative evaluation of the trial.

DESIGN

Multicenter, parallel-group, open-label, mixed-methods randomized controlled trial (RCT).

SUBJECTS AND SETTING

The sample comprised patients from a preceding case-finding study who reported fecal incontinence and met study requirements; the RCT was delivered via IBD outpatient clinics in 6 hospitals (5 in major UK cities, 1 rural) between September 2015 and August 2017. Sixteen participants and 11 staff members were interviewed for qualitative evaluation.

METHODS

Adults with IBD completed the study activities over a 3-month period following randomization. Each participant received either four 30-minute structured sessions with an IBD clinical nurse specialist and a self-management booklet or the booklet alone. Low retention numbers precluded statistical analysis; individual face-to-face or telephone interviews, recorded digitally and transcribed professionally, were conducted to evaluate the RCT. Transcripts were analyzed thematically using an inductive method.

RESULTS

Sixty-seven participants (36%) of the targeted 186 participants were recruited. The groups comprised 32 participants (17% of targeted participants) allocated to the nurse + booklet intervention and 35 (18.8% of targeted participants) allocated to the booklet alone. Less than one-third (n = 21, 31.3%) completed the study. Given the low recruitment and high attrition, statistical analysis of quantitative data was considered futile. Participant interviews were conducted concerning study participation and 4 themes emerged that described experiences of patients and staff. These data provided insights into reasons for low recruitment and high attrition, as well as challenges of delivering resource-heavy studies in busy health service environments.

CONCLUSIONS

Alternative approaches to trials of nurse-led interventions in hospital settings are needed as many interfering factors may prevent successful completion.

Universal Urogynecologic Consultation and Screening for Fecal Incontinence in Pregnant Women With a History of Obstetric Anal Sphincter Injury: A Cost-Effectiveness Analysis

IMPORTANCE

Obstetric anal sphincter injuries (OASIS) predispose for the development of fecal incontinence (FI), but management of subsequent pregnancy after OASIS is controversial.

OBJECTIVE

We aimed to determine if universal urogynecologic consultation (UUC) for pregnant women with prior OASIS is cost-effective.

STUDY DESIGN

We performed a cost-effectiveness analysis of pregnant women with a history of OASIS modeling UUC compared with no referral (usual care). We modeled the route of delivery, peripartum complications, and subsequent treatment options for FI. Probabilities and utilities were obtained from published literature. Costs using a third-party payer perspective were gathered from the Medicare physician fee schedule reimbursement data or published literature converted to 2019 U.S. dollars. Cost-effectiveness was determined using incremental cost-effectiveness ratios).

RESULTS

Our model demonstrated that UUC for pregnant patients with prior OASIS was cost-effective. Compared with usual care, the incremental cost-effectiveness ratio for this strategy was $19,858.32 per quality-adjusted life-year, below the willingness to pay a threshold of $50,000/quality-adjusted life-year. Universal urogynecologic consultation reduced the ultimate rate of FI from 25.33% to 22.67% and reduced patients living with untreated FI from 17.36% to 1.49%. Universal urogynecologic consultation increased the use of physical therapy by 14.14%, whereas rates of sacral neuromodulation and sphincteroplasty increased by only 2.48% and 0.58%, respectively. Universal urogynecologic consultation reduced the rate of vaginal delivery from 97.26% to 72.42%, which in turn led to a 1.15% increase in peripartum maternal complications.

CONCLUSIONS

Universal urogynecologic consultation in women with a history of OASIS is a cost-effective strategy that decreases the overall incidence of FI, increases treatment utilization for FI, and only marginally increases the risk of maternal morbidity.

Anal incontinence incidence is high in patients with obesity prior to bariatric surgery: Prevalence, risks-factors

INTRODUCTION

Anal incontinence (AI) prevalence in general population is estimate to range from 1.4 to 19.5% (Wexner ≥ 1). Obesity could be an AI risk factor. However, AI prevalence in patients with obesity is not clearly established. The main objective of this study was to assess the prevalence of AI in patients with extreme obesity prior to bariatric surgery and to identify specific AI risk factors in this subset of patients.

MATERIAL

A cross-sectional study, in a tertiary referral center in obesity was performed during one year. Patients who presented criteria for bariatric surgery (BMI>40 or BMI > 35 with co-morbidities) were asked to fill in preoperative self-questionnaires. A Wexner score ≥ 3 was used to define AI to identified patients who had a clinic impact of AI, by frequency of symptoms or alteration of quality of life.

RESULTS

Two hundred and fifty patients were included. Corresponded to, 196 women (78.4%) and 54 men (21.6%). Median BMI was 44.53kg/m². AI was diagnosed in 41 patients (prevalence 16.4%, 95CI 0.59). Constipation, urinary incontinence and the history of pregnancy (P = 0.03, OR 2.79; P = 0.01, OR 3.53 and P=0.02, OR 4.71, respectively) were significantly associated with AI.

CONCLUSION

AI is frequently observed in patients with extreme obesity scheduled for bariatric surgery and should be routinely evaluated. Modifiable risk factors as constipation should be manage before surgery as well as the specific management of AI, to prevent AI exacerbation after surgery. The choice of bariatric surgical procedure should be discussed and evaluated for the treatment of patients with obesity and AI.

LEVEL OF EVIDENCE

Moderate.

Innovative training modality for sacral neuromodulation (SNM): Patient-specific computerized tomography (CT) reconstructed 3D-printed training system: ICS School of Modern Technology novel training modality

INTRODUCTION

Sacral neuromodulation (SNM) is an effective treatment of urinary and bowel dysfunction, including secondary to neurological disorders. The learning curve for the optimal electrode placement for SNM is steep, expensive, and limited by patient factors such as obesity and previous injuries. We aim to create a patient specific 3-dimensional (3D) model for successful SNM training.

MATERIALS AND METHODS

A total of 26 urology residents who had different level of knowledge and experience were enrolled to the 3D SNM training program. The creation of 3D sacrum model has been started with evaluation of real patient computerized tomography images and creation of Digital Imaging and Communications in Medicine files. The segmented anatomic structures from the files then edited and stereolithographic files were generated for 3D-model prints via Mimics^© software. The 3D-printed models were used for training and evaluation of participants during the SNM intervention was performed. The evaluation of 3D SNM model training was led by one mentor who is expert on SNM.

RESULTS

On the preprinted 3D sacrum model all 26 participants were requested to perform the essential steps to complete a SNM procedure and individual procedure time was recorded. The mean and median scores were 18.8 and 19, respectively according to Likert scores (min 11 max 28).

CONCLUSIONS

SNM is increasing in popularity as a treatment option with physicians and patients with refractory symptoms. Few experienced specialists exist, and more effective training methods are needed to tackle the increasing demand, and individual patient anatomy.

Cell shape characteristics of human skeletal muscle cells as a predictor of myogenic competency: A new paradigm towards precision cell therapy

Skeletal muscle-derived cells (SMDC) hold tremendous potential for replenishing dysfunctional muscle lost due to disease or trauma. Current therapeutic usage of SMDC relies on harvesting autologous cells from muscle biopsies that are subsequently expanded in vitro before re-implantation into the patient. Heterogeneity can arise from multiple factors including quality of the starting biopsy, age and comorbidity affecting the processed SMDC. Quality attributes intended for clinical use often focus on minimum levels of myogenic cell marker expression. Such approaches do not evaluate the likelihood of SMDC to differentiate and form myofibres when implanted in vivo, which ultimately determines the likelihood of muscle regeneration. Predicting the therapeutic potency of SMDC in vitro prior to implantation is key to developing successful therapeutics in regenerative medicine and reducing implementation costs. Here, we report on the development of a novel SMDC profiling tool to examine populations of cells in vitro derived from different donors. We developed an image-based pipeline to quantify morphological features and extracted cell shape descriptors. We investigated whether these could predict heterogeneity in the formation of myotubes and correlate with the myogenic fusion index. Several of the early cell shape characteristics were found to negatively correlate with the fusion index. These included total area occupied by cells, area shape, bounding box area, compactness, equivalent diameter, minimum ferret diameter, minor axis length and perimeter of SMDC at 24 h after initiating culture. The information extracted with our approach indicates live cell imaging can detect a range of cell phenotypes based on cell-shape alone and preserving cell integrity could be used to predict propensity to form myotubes in vitro and functional tissue in vivo.

Risk factors accounting for anal incontinence during the first year after vaginal delivery-A case control study in China

Introduction and hypothesis

Anal incontinence (AI) is a prevalent postpartum disorder. This study aims to investigate and quantify the risk factors for AI in the Chinese population during the first year following vaginal delivery.

Methods

The case control study was conducted at Peking University Third Hospital, including all women who delivered vaginally between January 1, 2014, and June 30, 2018. Participants were followed up by telephone interviews 1 year after delivery. AI was defined as the involuntary loss of flatus or feces using a retrospective Jorge and Wexner score above 0. Clinical data were retrieved from the medical record system. Univariate and multivariate analyses were applied to identify potential risk factors accounting for AI. Based on the logistic regression model, a nomogram was constructed to predict the probability of AI postpartum. Restricted cubic spline was utilized to explore potential non-linear relationships between birth weight and AI postpartum.

Results

Among the 140 AI and 421 none AI cases, we observed antepartum factors like every 100 g of birth weight gain (OR 1.39, 95% CI 1.30-1.49), while intrapartum factors like forceps-assisted vaginal delivery (OR 7.11, 95% CI 2.60-19.45), midline episiotomy (OR 13.11, 95% CI 1.71-100.89), second-degree perineal tear (OR 6.51, 95% CI 1.16-36.68), and third to fourth-degree perineal tear were independent risk factors for postpartum AI. Significantly, infant weighing over 3,400 g at birth increased the risk of AI postpartum. Based on logistic regression model, we constructed a nomogram to estimate the risk of AI 1 year after vaginal delivery.

Conclusion

Our findings indicated that during the first year following vaginal delivery, infant with birth weight of 3,400 g or more, forceps-assisted vaginal delivery, midline episiotomy, and second to fourth-degree perineal tear increased the risk of AI. As a result, it is essential to limit the routine use of forceps and midline episiotomy and to monitor fetal weight during prenatal care.

Symptoms of anal incontinence and quality of life: a psychometric study of the Norwegian version of the ICIQ-B amongst hospital outpatients

BACKGROUND

The International Consultation on Incontinence Questionnaire-Bowel (ICIQ-B), a self-report, condition-specific questionnaire designed to assess symptoms of anal incontinence (AI), measures AI's impact on quality of life (QoL) along with perceived bowel patterns and bowel control amongst individuals with AI. In our study, we aimed to translate the ICIQ-B to Norwegian and investigate the Norwegian version's psychometric properties.

METHODS

To establish a relevant, comprehensive, and understandable Norwegian ICIQ-B, cognitive interviews were conducted with 10 patients with AI, and six clinical experts reviewed the translated scale. The Norwegian ICIQ-B's structural validity, scale reliability, and content validity were tested amongst patients with AI attending hospital outpatient clinics in three regions of Norway (N = 208).

RESULTS

Assessing the Norwegian ICIQ-B's content validity revealed that the questionnaire was relevant, comprehensive, and understandable. Missing data were infrequent (3.3%), and no floor or ceiling effects emerged. Three-factor and two-factor solution models, both with advantages and disadvantages, were found. The three-factor model offered the most parsimonious solution by covering most of the original scale, albeit with an unacceptably low reliability (α = .37) for the construct of bowel pattern. The two-factor model showed good reliability in terms of internal consistency for the constructs of bowel control (α = .80) and impact on QoL (α = .85) but was less parsimonious due to dismissing seven of the original 17 items and excluding the bowel pattern construct. Test-retest reliability demonstrates good stability for the Norwegian version, with an intra-class correlation coefficient of .90-.95 and weighted kappa of .39-.87 for single items.

CONCLUSIONS

Although the Norwegian version of ICIQ-B demonstrates good stability and content validity, the original constructs of bowel pattern and bowel control had to be adapted, whereas the construct of impact on QoL remained unchanged. Further psychometric testing of the Norwegian ICIQ-B's factor structure is therefore recommended.

Faecal incontinence is associated with an impaired rectosigmoid brake and improved by sacral neuromodulation

BACKGROUND

The rectosigmoid brake, characterised by retrograde cyclic motor patterns on high-resolution colonic manometry, has been postulated as a contributor to the maintenance of bowel continence. Sacral neuromodulation (SNM) is an effective therapy for faecal incontinence, but its mechanism of action is unclear. This study aims to investigate the colonic motility patterns in the distal colon of patients with faecal incontinence, and how these are modulated by SNM.

METHODS

A high-resolution fibreoptic colonic manometry catheter, containing 36 sensors spaced at 1-cm intervals, was positioned in patients with faecal incontinence undergoing stage 1 SNM. One hour of pre- and post meal recordings were obtained followed by pre- and post meal recordings with suprasensory SNM. A 700-kcal meal was given. Data were analysed to identify propagating contractions.

RESULTS

Fifteen patients with faecal incontinence were analysed. Patients had an abnormal meal response (fewer retrograde propagating contractions compared to controls; p = 0.027) and failed to show a post meal increase in propagating contractions (mean 17 ± 6/h premeal vs. 22 ± 9/h post meal, p = 0.438). Compared to baseline, SNM significantly increased the number of retrograde propagating contractions in the distal colon (8 ± 3/h premeal vs. 14 ± 3/h premeal with SNM, p = 0.028). Consuming a meal did not further increase the number of propagating contractions beyond the baseline upregulating effect of SNM.

CONCLUSION

The rectosigmoid brake was suppressed in this cohort of patients with faecal incontinence. SNM may exert a therapeutic effect by modulating this rectosigmoid brake.

Low Anterior Resection Syndrome: What Have We Learned Assessing a Large Population?

Our goal was to assess the rate of symptoms commonly included in LARS score in a large general population. The study was based on a population-based design. We disseminated LARS scores through community online platforms and general practitioners throughout Lithuania. We received 8183 responses to the questionnaire. There were 142 (1.74%) participants who were excluded for lack of information. There were 6100 (75.9%) females and 1941 (24.1%) males. After adjusting for sex and age, male participants had a significant average score of 18.4 (SD ± 10.35) and female 20.3 (SD ± 9.74) p < 0.001. There were 36.4% of participants who had minor LARS symptoms, and 14.2% who had major LARS symptoms. Overall, major LARS-related symptoms were significantly related to previous operations: 863 participants in the operated group (71.7%), and 340 in the non-operated group (28.3%; p0.001). In 51−75-year-old patients, major LARS was significantly more prevalent with 22.7% (p < 0.001) and increasing with age, with a higher incidence of females after the age of 75. After excluding colorectal and perineal procedures, the results of multivariate logistic regression analysis indicated the use of neurological drugs and gynaecological operations were independent risk factors for major LARS−odd ratio of 1.6 (p = 0.018, SI 1.2−2.1) and 1.28 (p = 0.018, SI 1.07−1.53), respectively. The symptoms included in the LARS score are common in the general population, and there is a variety of factors that influence this, including previous surgeries, age, sex, comorbidities, and medication. These factors should be considered when interpreting the LARS score following low anterior resection and when considering treatment options preoperatively.

Faecal incontinence in adults

Faecal incontinence, which is defined by the unintentional loss of solid or liquid stool, has a worldwide prevalence of ≤7% in community-dwelling adults and can markedly impair quality of life. Nonetheless, many patients might not volunteer the symptom owing to embarrassment. Bowel disturbances, particularly diarrhoea, anal sphincter trauma (obstetrical injury or previous surgery), rectal urgency and burden of chronic illness are the main risk factors for faecal incontinence; others include neurological disorders, inflammatory bowel disease and pelvic floor anatomical disturbances. Faecal incontinence is classified by its type (urge, passive or combined), aetiology (anorectal disturbance, bowel symptoms or both) and severity, which is derived from the frequency, volume, consistency and nature (urge or passive) of stool leakage. Guided by the clinical features, diagnostic tests and therapies are implemented stepwise. When simple measures (for example, bowel modifiers such as fibre supplements, laxatives and anti-diarrhoeal agents) fail, anorectal manometry and other tests (endoanal imaging, defecography, rectal compliance and sensation, and anal neurophysiological tests) are performed as necessary. Non-surgical options (diet and lifestyle modification, behavioural measures, including biofeedback therapy, pharmacotherapy for constipation or diarrhoea, and anal or vaginal barrier devices) are often effective, especially in patients with mild faecal incontinence. Thereafter, perianal bulking agents, sacral neuromodulation and other surgeries may be considered when necessary.

Pilot study of an adult bowel management program for fecal incontinence

OBJECTIVE

Bowel management programs are efficacious in pediatric patients with fecal incontinence or intractable constipation unresponsive to standard treatment. No studies have been done examining outcomes in adults. The objective of this study was to assess continence and quality of life outcomes in adults who have underwent bowel management program.

METHODS

A retrospective review of patients 16 or older at the time they underwent a bowel management program for fecal incontinence or constipation was performed. Data collected included intake and follow-up stool and urinary continence, patient-reported outcomes measures (Cleveland Clinic Constipation Score, Baylor Continence Scale, Vancouver Symptom Score for Dysfunctional Elimination), and an age-adjusted health-related quality of life measure.

RESULTS

The cohort included 38 patients with a median age of 19 years (range: 16-55) when they underwent our program. 50% of patients were female and the majority (33, 87%) were White. The most common diagnosis was anorectal malformation (16, 42%) followed by functional constipation (10, 27%). Stool continence rates improved after undergoing the program (52.7% prior to 87.6% at follow-up, p<0.01). There was significant improvement in the Baylor Continence Scale, Cleveland Clinic Constipation Score, and PedsQL (p<0.05).

CONCLUSIONS

Adult patients who underwent a bowel management program for severe fecal incontinence or constipation show significant improvement in stool continence rates, patient-reported outcomes measures, and quality of life. A bowel management program (in-person or via telemedicine) is a feasible treatment strategy for adult patients who fail standard management of fecal incontinence or constipation and should be offered when appropriate.

LEVEL OF EVIDENCE

III.

A short- and long-term follow-up study of intersphincteric NASHA Dx implants for fecal incontinence

BACKGROUND

The bulking agent NASHA Dx injected into the submucosal layer is effective in the treatment of fecal incontinence (FI) at short-and medium-term follow-up but efficacy after injection in the intersphincteric location is unknown. The aim of this study was to determine the short- and long-term efficacy and safety of NASHA Dx injected into the intersphincteric location for FI.

METHODS

Patients were recruited from referrals to our Department for treatment of FI in November 2008-January 2010. Eligible patients were injected with 8 ml of NASHA Dx. Patients with a subtotal treatment effect were retreated after 2-4 weeks. The change in number of fecal incontinence episodes, the proportion of responders defined as at least 50% decrease in number of FI episodes and side effects were the main outcome measures.

RESULTS

Sixteen patients, 15 women and 1 man with a median age of 68, 5 (range 44-80) years and a median CCFIS of 15 (range 10-19) were included in the study. The median number of incontinence episodes decreased from 21.5 (range 8-61) at baseline to 10 (range 0-30) at 6 months (p = 0.003) and 6 (range 0-44) at 12 months (p = 0.05). The median number of incontinence episodes in the 11 patients completing the 10-year follow-up was 26.5 (range 0-68). The percentage of responders at 12 months and 10 years were 56% and 27%, respectively. Mild to moderate pain at the injection site was described by 69%. There was one case of mild infection, successfully treated with antibiotics and one implant had to be removed due to dislocation.

CONCLUSIONS

NASHA Dx as an intersphincteric implant improves incontinence symptoms in the short term with moderate side effects and can be used alone or as an adjunct to other treatment modalities. Long-term efficacy was observed in 27%.

Comparison of surgical techniques for optimal lead placement in sacral neuromodulation: a cadaver study

Background

Sacral neuromodulation (SNM) is a common treatment for patients with urinary and faecal incontinence. A close contact of the tined lead electrode with the targeted nerve is likely to improve functional outcome.

The aim of this study was to compare the position of the SNM lead in relation to the sacral nerve by comparing different implantation techniques.

Methods

This cadaver study was conducted at the Division of Anatomy of Vienna's Medical University in October 2020. We dissected 10 cadavers after bilateral SNM lead implantation (n = 20), using two different standardized implantation techniques. The cadavers were categorized as group A (n = 10), representing the conventional guided implantation group and group B (n = 10), where SNM implantation was conducted with the novel fluoroscopy-guided “H”-technique. The primary goal was to assess the distance between the sacral nerve and the lead placement.

Results

The electrodes were inserted at a median angle of 58.5° (46–65°) in group A and 60° (50–65°) in group B, without reaching statistical significance. In 8 cadavers, the lead entered the S3 foramen successfully.

The median distance of the lead to the nerve did not show a significant difference between both groups (E0: Group A: 0.0 mm vs. Group B: 0.0 mm, p = 0.969; E1: Group A: 0.0 mm vs. Group B: 0.5 mm p = 0.754; E2: Group A: 2.5 mm vs. Group B: 2.5 mm p = 1.000; E3: Group A: 3.5 mm vs. Group B: 4.0 mm p = 0.675). In 2 cases (20%) of the conventional group A, the lead was misplaced and located at the gluteal muscle.

Perforation of the presacral fascia was observed in one lead placement in group A and in two placements in group B.

Conclusions

Both standardized implantation techniques may ensure close electrode proximity to the targeted nerve. Misplacement of the electrode was more often observed with the conventional implantation technique.

An evaluation of the long-term effectiveness of Gatekeeper™ intersphincteric implants for passive faecal incontinence

Background

Implantation of Gatekeeper™ prostheses presents an option for the treatment of passive faecal incontinence (FI). Whilst preliminary results are encouraging, long-term data regarding its sustained benefit are limited. The aim of this study was to assess and evaluate the long-term clinical function and quality of life of patients with passive faecal incontinence who were treated with Gatekeeper™ prostheses.

Methods

This was a single centre, single surgeon retrospective study of prospectively collected clinical data in patients with FI treated between June 2012 and May 2019. Patients with passive FI with symptoms refractory to conservative treatment and endoanal ultrasonography showing intact or disrupted internal anal sphincter were included. Formal clinical and quality of life assessments were carried out using the St. Mark’s Incontinence Score (SMIS) and Faecal Incontinence Quality of Life (FIQoL) questionnaires at baseline, 3 months, 6 months, 12 months and then annually. Endoanal ultrasonography was performed both before and after surgery.

Results

Forty patients (14 males, 26 females) with a median age of 62.5 (range 33–80) years were treated with the Gatekeeper™ implant. The majority of patients (87.5%) received six implants. There were no peri or post-operative complications. Prosthesis migration was observed in 12.5% patients. The median follow-up duration was 5 years (interquartile range (IQR) 3.25–6.00 years). A sustained improvement in median SMIS and FIQoL scores from baseline to follow-up was noted. Significant differences were observed between the median baseline SMIS score and last follow-up score of 16.00 (IQR 15.00–16.75) to 7.00 (IQR 5.00–8.00) respectively (p < 0.001), a 56.25% decrease. The overall median FIQoL score showed a significant improvement from 7.95 (IQR 7.13–9.48) to 13.15 (IQR 12.00–13.98) (p < 0.001) a 65.40% increase.

Conclusions

Gatekeeper™ implantation is a safe approach to treating passive FI and is minimally invasive, reproducible and has minimal complications. Long-term sustained clinical improvement is achievable beyond 5 years. Careful patient selection is paramount, as is consistency of technique and follow-up protocol.

Fecal incontinence in nonpregnant nulliparous women aged 25 to 64 years-a randomly selected national cohort prevalence study

BACKGROUND

The extent to which fecal incontinence is associated with obstetrical history or pelvic floor injuries is still a controversial and unresolved issue. One crucial first step toward answering this question is the need to study fecal incontinence in nonpregnant, nulliparous women.

OBJECTIVE

The aim of this study was to present detailed, descriptive measures of the accidental leakage of liquid or solid stool and gas in a randomly selected, large national cohort of nonpregnant, nulliparous women aged 25 to 64 years.

STUDY DESIGN

The Swedish Total Population Register identified the source population. Four independent, age-stratified, simple random samples in a total of 20,000 nulliparous women aged 25 to 64 years were drawn from 625,810 eligible women. Information was collected in 2014 using postal and web-based questionnaires. The 40-item questionnaire included questions about the presence and frequency of the leakage of solid and liquid stool and gas, which provided the basis for the generic terms fecal and anal incontinence. Statistical analyses of the differences between the groups were performed using the Fisher's exact test for dichotomous variables and the Mann-Whitney U-test for continuous variables. The trend between >2 ordered categories of dichotomous variables was analyzed with Mantel-Haenszel statistics. When analyzing the trend between multiple ordered vs nonordered categorical variables, the Kruskal-Wallis test was used. The age-related probability and risk increase per 10 years for incontinence parameters was calculated from logistic regression models adjusted for body mass index.

RESULTS

The study population was 9197 women, and the response rate was 52.2%, ranging from 44.7% in women aged 25 to 34 years to 62.4% among those from 55 to 64 years. All the types of incontinence, except severe isolated gas incontinence, increased with age up to 64 years. The estimated probability of fecal incontinence was 8.8% at age 25 years and 17.6% at age 64. The leakage of liquid stool was dominant, occurring in 93.1% (95% confidence interval, 91.4-94.5) of the women with fecal incontinence, whereas leakage of solid stool occurred in 33.9% (95% confidence interval, 31.1-36.7), of which approximately 80% also had concomitant leakage of liquid stool. The leakage of liquid stool increased markedly up to age 65, whereas the increase in the isolated leakage of solid stool was negligible across all ages (overall <0.4%). Liquid and solid stool, separate or in combination, co-occurred with gas in approximately 80%. The distribution pattern of the different types of leakage, single or combined, was similar in all the age groups. Both age and body mass index (kg/m2) were risk factors for fecal incontinence (P<.0001), with an interaction effect of P=.16.

CONCLUSION

Abnormal stool consistency has been identified as the strongest risk factor for accidental bowel leakage. The same pattern characterized by a dominance of liquid stool and gas leakage, prevalent concomitant leakage of solid and liquid stool, and a negligible rate of isolated leakage of solid feces was observed across all ages. The low rates of isolated leakage of solid stool support the impression that dysfunction of the continence mechanism of the pelvic floor had a negligible role for bowel incontinence, which is essential information for comparison with women with birth-related injuries.

A prospective trial of the THD SphinKeeper® for faecal incontinence

AIM

THD SphinKeeper® is an emerging surgical technique for faecal incontinence (FI). The safety, indications and efficacy of the procedure are still being investigated. The aim of this study is to present the first experience of SphinKeeper® in Australia.

METHOD

This was a prospective single-centre observational study of patients undergoing SphinKeeper® implantation between February 2018 and September 2019. Baseline demographics, intraoperative and postoperative complications, Cleveland Clinic Faecal Incontinence Score, St Mark's Incontinence Score, Faecal Incontinence Quality of Life score (FIQOL), anorectal manometry and endo-anal ultrasound were assessed preoperatively and 3 and 12 months after implantation.

RESULTS

Thirteen patients (2 male, 11 female) underwent implantation during the study period. Anal sphincter defects were present in 13 (76.9%) patients [external anal sphincter (EAS) defect, 2 (15.4%); internal anal sphincter (IAS) defect 4 (30.8%); EAS + IAS defect, 4 (30.8%)]. Median follow-up was 32 months (range 18-37 months). There were four complications: one intraoperative (rectal perforation) and three postoperative (one implant extrusion, two implants that required removal due to malposition). At 12 months, an average of 9/10 implants remained ideally placed in each patient. THD SphinKeeper® insertion was associated with an improvement in coping/behaviour as measured using FIQOL (p = 0.047). However, the procedure did not improve FI scores or anorectal manometry parameters.

CONCLUSION

In this study, SphinKeeper® marginally improved symptoms of FI but there was no significant impact on anorectal manometric measurements. Larger-scale studies are needed to determine the patient cohort most likely to benefit from this procedure.

Transanal irrigation at a glance

This article provides a brief overview of transanal irrigation (TAI). It covers the rationale behind the procedure, the contraindications, possible complications and considerations for patient education and support.

Women's experiences of obstetric anal sphincter injury and physical therapy interventions - A qualitative study

•

85% of all vaginal deliveries cause some form of obstetric tear injury.

•

The experienced recovery appears partially independent from the extent of injury.

•

Women feel uncertainty about what's normal after a vaginal tear.

•

Meeting each woman's needs and wishes in rehabilitation should be emphasized.

Background

During childbirth, women may suffer perineal injuries that can lead to persistent disorders. No interview study has investigated women's experience of obstetric anal sphincter injuries (OASIS) and physical therapy rehabilitation process after the injury.

Objective

To describe women's experiences of OASIS and the physical therapy rehabilitation process.

Methods

A qualitative study with an inductive approach based on semi-structured interviews was performed with 14 primi- and multi-parous women affected by OASIS. They had been sutured within 24 h and were recruited from a university hospital in Sweden. The interviews lasted between 35 and 66 min. Data were processed and analyzed using qualitative content analysis.

Results

Three main categories emerged from the analysis: The categories described experiences of a difficult time after the injury and physical therapy rehabilitation but also experiences of a safe follow-up. Moreover, experiences of that it wasn´t that bad after all when looking back.

Conclusion

Regardless of the extent of the injury, some women experienced a long and troublesome recovery with intense physical therapy rehabilitation, while other women felt that they fortunately got away lightly. Factors that can influence a woman's confidence in safely beginning pelvic floor muscle training at an early stage include individualizing when and how information about OASIS is provided. Meeting each woman's needs and wishes is emphasized by this study.

Prevalence of pelvic floor dysfunction: a Saudi national survey

BACKGROUND

Pelvic Floor Dysfunction (PFD) is a global health problem affecting millions of women worldwide and comprises a broad range of clinical dysfunctions such as urinary incontinence (UI), fecal incontinence (FI), pelvic organ prolapse (POP) vaginal laxity (VL), vaginal wind (VW), and overactive bladder (OAB). This study aims to estimate the prevalence of PFD among Saudi women attending primary health care centers (PHCCs) across 13 regions of Saudi Arabia and their characteristics along with associated factors.

METHODS

A cross-sectional study was conducted on 2,289 non-pregnant women. The probability population proportional sampling technique was employed followed by a convenient sampling technique to recruit eligible women. Types of PFD were assessed using a self-administered electronic questionnaire. Pelvic Floor Distress Index (PFDI-20) was used to assess the primary study outcomes (FI, VL, POP, VW, and OAB). A multivariate logistic regression model was used to identify independent associated factors for PFD.

RESULTS

The findings showed that 830 women (36.3%) had any type of UI. Stress UI affected726 (31.7%) women, whilst 525 women (22.9%) had urge UI. VL occurred in 505 women (22.1%), whilst POP occurred in 536 women (23.4%). VW occurred in 733 participants and (32%) 1238 women (54.1%) had OAB. The multivariate analysis suggested that region, location, parity, and assisted birth were significantly associated with UI, VL, FI and PFD (P < 0.001).

CONCLUSION

PFD is a common condition among Saudi women. UI, VL, VW, OAB, POP and FI increased consistently among urban women with increased age, greater parity, assisted birth, and post-menopausal status.

Art of connectedness: Value-creating care for older persons provided with toileting assistance and containment strategies-A critical interpretive synthesis

AIMS AND OBJECTIVES

The aim was to conduct a synthesis of the literature on value-creating care for older persons with incontinence provided with toileting assistance and containment strategies, from the perspectives of older persons and healthcare professionals.

BACKGROUND

Incontinence is a health problem for many persons worldwide and the problem will increase as the global population ages. It can have a profound impact on a person's wellbeing, and assistance with toileting and containment strategies is common in home care settings and nursing homes.

DESIGN

The design was a literature review with an iterative, reflexive and critical approach.

METHODS

A critical interpretive synthesis was conducted. Ten papers published between 2011 and 2019 were analysed. The PRISMA -ScR Checklist was used in this review.

RESULTS

Based on the findings, the conceptual construct 'The art of connectedness' was developed, built on co-created care, personalised care and reflective care between the older person and healthcare professionals. Co-created care is based on establishing a relationship, building trust and respecting preferences. Personalised care consists of meeting the person's needs, promoting comfort and maintaining self-determination. Reflective care entails showing empathy, upholding the person's dignity and developing professional competence.

CONCLUSIONS

Value-creating care consists conceptually of a connectedness that starts with co-creating the care together with the older person in a close relationship. Assistance is given and received based on the older person's individual needs and is highly valued by the older person as it helps them maintain self-determination. Reflective care is of importance for healthcare professionals.

RELEVANCE FOR PRACTICE

The findings are hoped to enhance healthcare professionals' understanding of how to improve the clinical encounter in nursing when providing assistance. They may also stimulate critical reflection among healthcare professionals on how to improve assistance to meet the older person's values.

Fecal incontinence: incidence and risk factors from the SABE (Health, Wellbeing and Aging) study

INTRODUCTION AND HYPOTHESIS

This study aimed to estimate the incidence of fecal incontinence (FI) and identify risk factors in a cohort of older individuals.

METHODS

In 2006, individuals aged ≥ 60 years were selected from the SABE study. The dependent variable was FI in 2010. FI was assessed using the question: "In the last 12 months, have you ever lost control of bowel movements or stools?" Incidence was measured in units of per 1000 person-years. Multivariate analysis was used to assess risk factors for FI.

RESULTS

This study was the first to examine the incidence of FI in older Brazilian individuals. In total, 1413 individuals were included; mean age was 74.5 years, and 864 (61.8%) participants were women. FI prevalence rates were 4.7% for men and 7.3% for women. Incidence rate of FI was 16.3 and 22.2 per 1000 person-years for men and women, respectively. The risk of FI was greater among women aged ≥ 75 years, with severe symptoms of depression, cancer (other than skin) and chronic obstructive pulmonary disease (COPD). In men, the risk of FI was greater among those with poor literacy (up to 3 years of schooling), an Instrumental Activities of Daily Living (IADL) category of 1-4 and those who self-reported "bad/very bad" health status.

CONCLUSIONS

The FI incidence rate was high. The identified risk factors were age ≥ 75 years, with severe symptoms of depression, cancer and COPD (women); having up to 8 years of schooling; IADL category of 1-4 and self-reported health status (men).

Critical appraisal of international guidelines for the management of fecal incontinence in adults: is it possible to define what to do in different clinical scenarios?

Fecal incontinence (FI) is a complex often multifactorial functional disorder which is associated with a significant impact on patients’ quality of life. There is a broad spectrum of symptoms, and degrees of severity and diverse patient backgrounds. Several treatment algorithms from different professional societies and experts are available in the literature. However, no consensus has been reached on several aspects of FI management. We performed a critical review of the most recently published guidelines on FI, emphasising the lack of consensus, highlighting specific topics mentioned in each of the guidelines that are not covered in the others and defining the treatment proposed in different clinical scenarios.

Sphinkeeper Procedure for Treating Severe Faecal Incontinence-A Prospective Cohort Study

(1) Background: The Sphinkeeper implantation for faecal incontinence (FI) is a novel surgical procedure with limited data on its clinical efficacy. Therefore, we aimed to assess the functional outcome following Sphinkeeper surgery in patients with refractory FI. (2) Methods: Between 2018 and 2020, eleven consecutive patients (9 female) with FI met the inclusion criteria and were enrolled for surgery. Functional outcome and quality of life were evaluated by standard questionnaires pre- and post-surgery. Migration of protheses was demonstrated by 3D endoanal ultrasound. The median follow-up time was eight months (range 3–18 months). (3) Results: The median age was 75 years (range 46–89 years) with a median BMI of 27.4 (range 21.2–30.1). The median number of implanted prostheses per intervention was nine (range 9–10). We found no intraoperative or early postoperative complications. After two months, two prostheses in one patient had to be removed due to pain at the perianal skin site. The median St. Mark’s incontinence score decreased significantly from 22 to 13 points (p = 0.008). The SF-12 showed a significant improvement (35.9 versus 46.3) after surgery (p = 0.028). A migration of at least one prosthesis was observed in ten patients (91%). Six (60%) prostheses were found at the same level in another ten patients. (4) Conclusion: Sphinkeeper implantation is a promising surgical technique for patients with severe FI. The complication rate is low, and short-term functional improvement can be achieved even in severe forms of FI. Migration of implants commonly occurs.

Intraoperative serosal extracellular mapping of the human distal colon: a feasibility study

BACKGROUND

Cyclic motor patterns (CMP) are the predominant motor pattern in the distal colon, and are important in both health and disease. Their origin, mechanism and relation to bioelectrical slow-waves remain incompletely understood. During abdominal surgery, an increase in the CMP occurs in the distal colon. This study aimed to evaluate the feasibility of detecting propagating slow waves and spike waves in the distal human colon through intraoperative, high-resolution (HR), serosal electrical mapping.

METHODS

HR electrical recordings were obtained from the distal colon using validated flexible PCB arrays (6 × 16 electrodes; 4 mm inter-electrode spacing; 2.4 cm2, 0.3 mm diameter) for up to 15 min. Passive unipolar signals were obtained and analysed.

RESULTS

Eleven patients (33-71 years; 6 females) undergoing colorectal surgery under general anaesthesia (4 with epidurals) were recruited. After artefact removal and comprehensive manual and automated analytics, events consistent with regular propagating activity between 2 and 6 cpm were not identified in any patient. Intermittent clusters of spike-like activities lasting 10-180 s with frequencies of each cluster ranging between 24 and 42 cpm, and an average amplitude of 0.54 ± 0.37 mV were recorded.

CONCLUSIONS

Intraoperative colonic serosal mapping in humans is feasible, but unlike in the stomach and small bowel, revealed no regular propagating electrical activity. Although sporadic, synchronous spike-wave events were identifiable. Alternative techniques are required to characterise the mechanisms underlying the hyperactive CMP observed in the intra- and post-operative period.

NEW FINDINGS

The aim of this study was to assess the feasibility of detecting propagating electrical activity that may correlate to the cyclic motor pattern in the distal human colon through intraoperative, high-resolution, serosal electrical mapping. High-resolution electrical mapping of the human colon revealed no regular propagating activity, but does reveal sporadic spike-wave events. These findings indicate that further research into appropriate techniques is required to identify the mechanism of hyperactive cyclic motor pattern observed in the intra- and post-operative period in humans.

Risk of Fecal Incontinence Following Receptive Anal Intercourse: Survey of 21,762 Men Who Have Sex With Men

BACKGROUND

The prevalence of receptive anal intercourse (RAI) is increasing. A few studies, with heterogeneous designs, have investigated the associated risk of fecal incontinence (FI).

AIM

The primary objective of this study was to determine FI prevalence in a population of men who have sex with men (MSM) engaging in RAI. The secondary objective was to identify risk factors for severe FI.

METHODS OUTCOMES

An online survey of 24,308 MSM was performed in 2019. Demographic and socioeconomic data were collected, together with information about RAI sexual practices, and FI defined by: "During the last month, have you experienced any involuntary leakage of stools?"

RESULTS CLINICAL IMPLICATIONS

In total, 1,734 (8%) of the 21,762 participants reported FI. Mean age was 35.3 years. The prevalence of FI was correlated with RAI frequency: 12.7% (if RAI ≥ 1 /wk) versus 5.7% (if no RAI). In multivariate analysis, the factors associated with FI were age (OR: 1.01), low socioeconomic status (OR 1.32 to 1.40), HIV-seropositivity (OR: 1.78), high RAI frequency (OR: 1.64), chemsex (OR: 1.67) and fist-fucking (OR: 1.61).

STRENGTHS AND LIMITATIONS

Main strengths of our study are population size and assessment of detailed modalities of sexual practices. Main limitations are the use of a convenience non-random sample and the assessment of FI only during the past month.

CONCLUSION

This study of a large MSM population, highlights risk factors for FI among RAI practices: RAI ≥ 1 /wk, chemsex, fist-fucking, low socioeconomic status. Garros A, Bourrely M, Sagaon-Teyssier L, et al. Risk of Fecal Incontinence Following Receptive Anal Intercourse: Survey of 21,762 Men Who Have Sex With Men. J Sex Med 2021;18:1880-1890.

Pelvic floor architectural defects in female patients with urge fecal incontinence versus passive fecal leakage: a dynamic ultrasound study

INTRODUCTION AND HYPOTHESIS

Fecal incontinence (FI) has two primary subtypes: urgency fecal incontinence (UFI) and passive fecal leakage (PFL). The pathophysiology underlying the subtypes is incompletely understood.

OBJECTIVES

To compare the bowel habits, physical examinations and pelvic floor anatomical defects in patients with UFI-dominant FI versus patients with PFL-dominant FI.

STUDY DESIGN

This is a retrospective cross-sectional study of female patients who presented with fecal incontinence symptoms to our tertiary urogynecology center. All subjects underwent a comprehensive history, physical examination, 3D-static pelvic floor ultrasound, and 2D-dynamic ultrasound of the posterior compartment. Patients with UFI-dominant FI were compared to patients with PFL-dominant FI.

RESULTS

One hundred forty-five patients were included in the analysis; 57 categorized as UFI-dominant FI, 69 PFL-dominant FI and 19 categorized as having "both" leakage patterns. In comparing bowel habits, patient with UFI-dominant FI had more frequent bowel movements (15.5 ± SD 13.0/week vs. 10.9 ± SD 7.6 /week, p = 0.022) and were more likely to have loose stools (48.2% vs. 26.1%, p = 0.01). No statistically significant differences were observed in the prevalence of external anal sphincter defect (11.3% vs. 17.2%, p = 0.38) or internal anal sphincter defect (11.3% vs. 19%, p = 0.26) between groups. Finally, patients with UFI-dominant FI had a higher incidence of rectal hypermobility (loss of rectal support on Valsalva) (58% vs. 36.9%, p = 0.025).

CONCLUSION

Patients with urge-predominant FI have increased frequency of bowel movements, looser stools, and increased rectal folding diagnosed via dynamic ultrasound as compared to patients with passive-dominant FI.

A comparison of faecal incontinence scoring systems

AIM

Questionnaires designed to score the severity of faecal incontinence (FI) are widely used to provide an evaluation of symptoms across settings, studies and time. The Pelvic Floor Disorders Consortium have recommended the use of multiple questionnaires despite some overlap of questions. This study aimed to evaluate whether patient responses to these questionnaires are consistent.

METHOD

A retrospective analysis was undertaken of patients with FI who attended a dedicated pelvic floor unit between January 2018 and December 2019 and completed the Fecal Incontinence Severity Index, Cleveland Clinic Florida Incontinence Score and St Mark's Incontinence Score simultaneously. For each questionnaire the frequency of incontinence episodes to solid stool, liquid stool and gas was divided into five categories to allow direct comparison. Answers were deemed equivalent if the allocated response was identical, slightly different if the response was in an adjacent category or very different if the response differed to a greater extent.

RESULTS

There were 193 patients who simultaneously completed all three FI questionnaires. There were statistically significant differences between the responses regarding frequency of solid stool, liquid stool and gas incontinence on all three questionnaires (p < 0.005). Across all domains, between 58.0% and 69.9% of responses were equivalent, 14.1%-34.0% of answers were slightly different and 8.0%-18.8% were very different.

CONCLUSION

Even when completed at the same time, and by the same person, similar questions are answered differently a significant proportion of the time. The utility of using multiple questionnaires simultaneously in the clinical setting to assess FI symptoms should be questioned.

Transanal Endoscopic Microsurgery (TEMS) for Rectal Cancer: Patient Decision-making, Postoperative Experience and Quality of Life

BACKGROUND/AIM

Transanal endoscopic microsurgery (TEMS) is a form of minimally invasive surgery for selected rectal cancers. The aim of this study was to explore the factors affecting patients' decision-making concerning the choice of surgical treatment as well as to measure the Quality of Life (QoL) post-TEMS.

PATIENTS AND METHODS

Thirty-four patients with rectal cancer stage T1/T2-N0-M0 that underwent TEMS were studied. The questionnaires used included the Short Form SF12v2, Wexner Score (CCF-FIS) and the Sexual Function Questionnaire (SFQ). The patients' views on experience and treatment decision were obtained with a custom-designed questionnaire. Questionnaires were completed at a mean of 6.9 years following treatment.

RESULTS

The factors that influenced the patients' decisions were: experience satisfaction (p=0.003), postoperative bowel function (p<0.001), lower incontinence score (p=0.020) and agreement of TEMS experience with preoperative information (p=0.049). Treatment experience satisfaction was associated with family support (p=0.034) and agreement with preoperative information (p=0.047), better bowel function (p=0.026) and mental QoL (MCS) (p=0.003).

CONCLUSION

factors important to patients when reflecting on treatment experience are adequate and reliable information, a good QoL and the presence of family support. Clinicians should incorporate those parameters in their practice when assisting patients in making a surgical treatment choice and provide informed consent on TEMS for rectal cancer.

Chronic constipation in adults: Contemporary perspectives and clinical challenges. 1: Epidemiology, diagnosis, clinical associations, pathophysiology and investigation

BACKGROUND

Chronic constipation is a prevalent disorder that affects patients' quality of life and consumes resources in healthcare systems worldwide. In clinical practice, it is still considered a challenge as clinicians frequently are unsure as to which treatments to use and when. Over a decade ago, a Neurogastroenterology & Motility journal supplement devoted to the investigation and management of constipation was published (2009; 21 (Suppl.2)). This included seven articles, disseminating all themes covered during a preceding 2-day meeting held in London, entitled "Current perspectives in chronic constipation: a scientific and clinical symposium." In October 2018, the 3rd London Masterclass, entitled "Contemporary management of constipation" was held, again over 2 days. All faculty members were invited to author two new review articles, which represent a collective synthesis of talks presented and discussions held during this meeting.

PURPOSE

This article represents the first of these reviews, addressing epidemiology, diagnosis, clinical associations, pathophysiology, and investigation. Clearly, not all aspects of the condition can be covered in adequate detail; hence, there is a focus on particular "hot topics" and themes that are of contemporary interest. The second review addresses management of chronic constipation, covering behavioral, conservative, medical, and surgical therapies.

Diagnostic approach to faecal incontinence: What test and when to perform?

Faecal incontinence (FI) is a debilitating common end result of several diseases affecting the quality of life and leading to patient disability, morbidity, and increased societal burden. Given the various causes of FI, it is important to assess and identify the underlying pathomechanisms. Several investigatory tools are available including high-resolution anorectal manometry, transrectal ultrasound, magnetic resonance imaging, and electromyography. This review article provides an overview on the causes and pathophysiology of FI and the author’s perspective of the stepwise investigation of patients with FI based on the available literature. Overall, high-resolution anorectal manometry should be the first investigatory tool for FI, followed by either transrectal ultrasound or magnetic resonance imaging for anal internal sphincter and external anal sphincter injury, respectively.

How Much Knowledge and Awareness of Faecal Incontinence Is There in Primary Care?

Faecal incontinence (FI) is a debilitating symptom with a likely underreported incidence in the general population. Postpartum or postmenopausal women are at increased risk of this. General Practitioners (GPs) have a vital role in screening patient groups with FI. Knowledge of the underlying diseases associated with FI is important for all clinicians who have contact with this patient group. An online questionnaire (Survey MonkeyTM, San Mateo, CA, USA) was sent to GPs in Wales and England through a deanery, social media and GP educational groups. Questions: A total of 250 participants completed the questionnaire—195 GPs and 55 GPSTs. Two-thirds had no coloproctology experience, but 70% had worked in obstetrics and gynaecology. In total, 70% had no formal FI training and 75% felt insufficiently informed about FI. A total of 80% felt that GPs need specific training on FI. A third of respondents used the 6-week postnatal check to assess maternal bowel function and most did not appreciate faecal urgency as a symptom. Patients should be asked about FI symptoms by GPs, particularly those populations at increased risk. Our GP survey participants were enthusiastic for more education on the treatment options and where to signpost patients with FI.