Treatment options for fecal incontinence

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.

Unstimulated Gluteus Maximus Sphincteroplasty for Bowel Incontinence

Background Gluteus maximus, by virtue of its continued adjunct contraction with the anal sphincter, has many characteristics and histomorphological features mimicking type I musculature. Hence, anal sphincter replacement therapy with gluteus maximus has all avenues for lasting successful results. This study aimed to evaluate the efficiency of unstimulated gluteus maximus sphincteroplasty for anal incontinence reconstruction and neosphincter reconstruction in perineal colostomy cases.

Methods From March 2015 to March 2020, the records of patients who underwent gluteus maximus sphincteroplasty for fecal incontinence were analyzed in this retrospective cohort study. The mean age was 31.55 years. Eleven patients (females = 4, males = 7) underwent anal incontinence reconstruction. All these cases were followed up for an average period of 28.46 months.

Results Good continence was observed in all patients with an average Cleveland Clinic Florida Faecal Incontinence Score of 3.18 (p = 0.0035). At the end of the follow-up period, the average median resting pressure found via manometry was 44.64 mm Hg, and the average median squeeze pressure was 103.55mm Hg. The mean of the average continence contraction time at the end of the follow-up period was found to be 3.64 minutes. None of our patients had complete continence failure. None of our patients used perineal pads or made any lifestyle alterations at the end of the follow-up period. Most of the patients expressed satisfactory continence.

Conclusion Despite being untrained with implantable electrodes, the gluteus maximus muscle produced very good continence results with our way of construct. In addition, with its good lumen occluding effect, it achieves good resting and squeeze anal pressure around the anal canal/bowel with trivial reeducation. Hence, it has become our institution's procedure of choice for anal sphincter reconstruction.

Usability evaluation of the Computer-Based Health Evaluation System (CHES) eDiary for patients with faecal incontinence: a pilot study

Background

Faecal incontinence (FI) is prevalent in 15–20% of elderly individuals and is frequently monitored in clinical trials and practice. Bowel diaries are the most common way to document FI, but, in clinical practice, are mainly used as paper-based versions. Electronic diaries (eDiaries) offer many potential benefits over paper-based diaries. The aim of this study was to develop and test an eDiary to document FI.

Methods

We migrated a paper FI diary to an eDiary app based on the Computer-based Health Evaluation System (CHES). To assess usability, we conducted functionality and usability tests at two time points in a sample of patients with FI. In the first assessment, the eDiary functionalities were tested, patients completed the System Usability Scale (SUS, range 0–100) and compared the paper diary with the eDiary. We set a threshold for minimum acceptable average usability at 70 points. Patients were then instructed to use the eDiary for 2 days at home and contacted to report on their usage and completed the SUS a second time.

Results

We recruited a sample of N = 14 patients to use the eDiary. All patients were able to use all functionalities of the eDiary and only a few patients with lower technological literacy or access to devices (n = 3) needed initial assistance. The mean usability rating given at the first time point was high with 88 points (SD 18, 95% CI 78.2–96.8) and most patients (n = 10) reported they would prefer the eDiary over the paper-based version. Nine patients (n = 9) participated in the follow-up assessment and the mean SUS rating at the second time point was 97 points (SD 7, 95% CI 92.8–100).

Conclusion

The eDiary showed excellent usability scores for the assessment of FI at both assessments. Generally, patients preferred the eDiary over the paper-based version. We recommend the eDiary for usage with patients who own and use a smartphone and discuss potential solutions for patients with lower technological literacy or access.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-01818-5.

The Role of Traditional Acupuncture in Patients with Fecal Incontinence-Mini-Review

OBJECTIVE

Fecal incontinence affects up to 15% of the general population, with higher rates of incidence among women and the elderly. Acupuncture is an old practice of Traditional Chinese Medicine that might be used to treat fecal incontinence. The aim of this mini review was to assess the effect of acupuncture for fecal incontinence.

MATERIALS AND METHODS

Cochrane Library, Web of Science, Embase, PubMed, and CENTRAL electronic databases were searched until August 2020. The following keywords were used: acupuncture, electroacupuncture, moxibustion, fecal incontinence, diarrhea, irritable bowel syndrome, and bowel dysfunction. In addition, references were searched. Five studies (two randomized controlled trials), out of 52,249 predefined publications after an electronic database search, were included into the review.

RESULTS

Overall, 143 patients were included. All studies report significant improvements in continence, although they all apply different acupuncture regimens. Randomized controlled trials show significant differences in experimental groups treated with acupuncture in improving continence. Significant improvement in quality of life scores was reported. In addition, improvement in fecal continence remained significantly improved after 18 months of follow-up.

CONCLUSION

Acupuncture is a promising treatment alternative for fecal incontinence. Based on small, low-quality studies, it might be a safe, inexpensive, and efficient method. However, more high-quality studies are needed in order to apply this treatment technique routinely.

Japanese Practice Guidelines for Fecal Incontinence Part 1-Definition, Epidemiology, Etiology, Pathophysiology and Causes, Risk Factors, Clinical Evaluations, and Symptomatic Scores and QoL Questionnaire for Clinical Evaluations-English Version

Fecal incontinence (FI) is defined as involuntary or uncontrollable loss of feces. Gas incontinence is defined as involuntary or uncontrollable loss of flatus, while anal incontinence is defined as the involuntary loss of feces or flatus. The prevalence of FI in people over 65 in Japan is 8.7% in the male population and 6.6% among females. The etiology of FI is usually not limited to one specific cause, with risk factors for FI including physiological factors, such as age and gender; comorbidities, such as diabetes and irritable bowel syndrome; and obstetric factors, such as multiple deliveries, home delivery, first vaginal delivery, and forceps delivery. In the initial clinical evaluation of FI, the factors responsible for individual symptoms are gathered from the history and examination of the anorectal region. The evaluation is the basis of all medical treatments for FI, including initial treatment, and also serves as a baseline for deciding the need for a specialized defecation function test and selecting treatment in stages. Following the general physical examination, together with history taking, inspection (including anoscope), and palpation (including digital anorectal and vaginal examination) of the anorectal area, clinicians can focus on the causes of FI. For the clinical evaluation of FI, it is useful to use Patient-Reported Outcome Measures (PROMs), such as scores and questionnaires, to evaluate the symptomatic severity of FI and its influence over quality of life (QoL).

Japanese Practice Guidelines for Fecal Incontinence Part 3 -Surgical Treatment for Fecal Incontinence, Fecal Incontinence in a Special Conditions- English Version

In Japan, the surgical treatment for fecal incontinence (FI) can be performed using minimally invasive surgery, such as anal sphincteroplasty and sacral neuromodulation (SNM), as well as antegrade continence enema (ACE), graciloplasty, and stoma construction. In addition, currently, several other procedures, including biomaterial injection therapy, artificial bowel sphincter (ABS), and magnetic anal sphincter (MAS), are unavailable in Japan but are performed in Western countries. The evidence level of surgical treatment for FI is generally low, except for novel procedures, such as SNM, which was covered by health insurance in Japan since 2014. Although the surgical treatment algorithm for FI has been chronologically modified, it should be sequentially selected, starting from the most minimally invasive procedure, as FI is a benign condition. Injuries to the neural system or spinal cord often cause disorders of the sensory and motor nerves that innervate the anus, rectum, and pelvic floor, leading to the difficulty in controlling bowel movement or FI and/or constipation. FI and constipation are closely associated; when one improves, the other tends to deteriorate. Patients with severe cognitive impairment may present with active soiling, referred to as "incontinence" episodes that occur as a consequence of abnormal behavior, and may also experience passive soiling.

Current Position of Sacral Neuromodulation in Treatment of Fecal Incontinence

Fecal incontinence (FI) is defined as uncontrolled passage of feces or gas for at least 1-month duration in an individual who previously had control. FI is a common and debilitating condition affecting many individuals. Continence depends on complex relationships between anal sphincters, rectal curvatures, rectoanal sensation, rectal compliance, stool consistency, and neurologic function. Factors, such as pregnancy, chronic diarrhea, diabetes mellitus, previous anorectal surgery, urinary incontinence, smoking, obesity, limited physical activity, white race, and neurologic disease, are known to be the risk factors for FI. Conservative/medical management including biofeedback are recognized as the first-line treatment of the FI. Those who are suitable for surgical intervention and who have failed conservative management, sacral nerve stimulation (SNS) has emerged as the treatment of choice in many patients. The surgical technique involves placement of a tined lead with four electrodes through the S3 sacral foramen. The lead is attached to a battery, which acts as a pulse generator, and is placed under the patient's skin in the lower lumbar region. The use of SNS in the treatment of FI has increased over the years and the beneficial effects of this treatment have been substantiated by multiple studies. This review describes SNS as a modality of treatment for FI and its position in the current medical diaspora in patients with FI.

Effectiveness of percutaneous posterior tibial nerve stimulation for the management of bowel dysfunction in multiple sclerosis patients

BACKGROUND

Neurogenic bowel dysfunctions (NBDs) in the form of both fecal incontinence (FI) and functional constipation (FC) are frequent in multiple sclerosis (MS) patients and significantly affect their quality of life. Therapeutic options are limited.

OBJECTIVE

To investigate effectiveness of percutaneous posterior tibial nerve stimulation (PTNS) in MS patients suffering from FI and FC.

METHODS

Prevalence and severity of FI and FC were prospectively collected among MS patients undergoing 12 weeks of PTNS for neurogenic bladder. The Cleveland Clinic Fecal Incontinence Score (CCFIS) and the Rome III criteria were used to define FI and FC, respectively. Subjective treatment satisfaction was estimated using the Benefit Satisfaction and Willingness to Continue (BSWC) questionnaire.

RESULTS

A total of 60 patients undergoing PTNS suffered from NBDs (25 FI+/FC+, 5 FI+/FC-, 30 FI-/FC+). Median CCFIS decreased after PTNS from 12.0 (11.0-13.0) to 8.5 (7.0-11.0, p < 0.001), with particular improvements in liquid and flatal incontinence, pads' need, and lifestyle restrictions. Seven patients became FC free after PTNS and no patients developed FC during the study (p = 0.023). More than 50% of the patients were satisfied and willing to continue PTNS at study end.

CONCLUSION

PTNS represents a valid minimally invasive alternative treatment for MS patients suffering from NBDs.

Human Histology and Persistence of Various Injectable Filler Substances for Soft Tissue Augmentation

An increasing number of soft tissue filler substances have been introduced to the beauty market outside the U.S. which lackexperimental and clinical data in support of their claim. Ten commercially available filler substances were examined for biocompatibility and durability: 0.1 cc of each substance was injected deep intradermally into the volar forearm of one of the authors and observed for clinical reaction and permanence. At 1, 3, 6, and 9 months the test sites were excised, histologically examined, and graded according to foreign body reactions classification. Collagen (Zyplast) was phagocytosed at 6 months and hyaluronic acid (Restylane) at 9 months. PMMA microspheres (Artecoll) had encapsulated with connective tissue, macrophages, and sporadic giant cells. Silicone oil (PMS 350) was clinically inconspicuous but dissipated into the tissue, causing a chronic foreign body reaction. Polylactic acid microspheres (New-Fill) induced a mild inflammatory response and had disappeared clinically at 4 months. Dextran microspheres (Reviderm intra) induced a pronounced foreign body reaction and had disappeared at 6 months. Polymethylacrylate particles (Dermalive) induced the lowest cellular reaction but had disappeared clinically at 6 months. Polyacrylamide (Aquamid) was well tolerated and remained palpable to a lessening degree over the entire testing period. Histologically, it dissipated more slowly and was kept in place through fine fibrous capsules. Polyvinylhydroxide microspheres suspended in acrylamide (Evolution) were well tolerated, slowly diminishing over 9 months. Calcium hydroxylapatite microspheres (Radiance FN) induced almost no foreign body reaction but were absorbed by the skin at 12 months.Host defense mechanisms react differently to the various filler materials, but all substances- resorbable or nonresorbable-appeared to be clinically and histologically safe, although all exhibit undesirable side effects. Since the mechanism of late inflammation or granuloma formation is still unknown, early histological findings are not useful in predicting possible late reactions to filler substances.

Effectiveness of Autologous Fat Graft in Treating Fecal Incontinence

Purpose

The most common risk factor for fecal incontinence (FI) is obstetric injury. FI affects 1.4%–18% of adults. Most patients are unaware when they are young, when symptoms appear suddenly and worsen with aging. Autologous fat graft is widely used in cosmetic surgical field and may substitute for injectable bulky agents in treating FI. Authors have done fat graft for past several years. This article reports the effectiveness of the fat graft in treating FI and discusses satisfaction with the procedure.

Methods

Fat was harvested from both lateral thighs using 10-mL Luer-loc syringe. Pure fat was extracted from harvests and mixed with fat, oil, and tumescent through refinement. Fats were injected into upper border of posterior ano-rectal ring, submucosa of anal canal and intersphincteric space. Thirty-five patients with FI were treated with this method from July 2016 to February 2017 in Busan Hangun Hospital. They were 13 male (mean age, 60.8 years) and 22 female patients (mean age, 63.3 years). The Wexner score was checked before procedure. We evaluated outcome in outpatients by asking the patients. For 19 patients we checked the Wexner score after procedure.

Results

Symptom improved in 29 (82.9%), and not improved in 6 (17.1%). In 2 of 6 patients, they felt better than before procedure, although not satisfied. No improvement in 4. Mean Wexner score was 9.7 before procedure. There were no serious complications such as inflammation or fat embolism.

Conclusion

Autologous fat graft can be an effective alternative treatment for FI. It is safe and easy to perform, and cost effective.

Acupuncture for fecal incontinence: Protocol for a systematic review and data mining

BACKGROUND

Fecal incontinence is a socially and emotionally destructive condition that has a negative impact on personal image, self-confidence, and quality of life. Acupuncture is commonly used to treat chronic conditions, including fecal incontinence. However, no relevant systematic review or meta-analysis has been designed to evaluate the effects of acupuncture on fecal incontinence.

METHODS

We will identify relevant randomized controlled trials (RCTs) from the Cochrane Library, Medline, Embase, PubMed, Springer, Web of Science, China National Knowledge Infrastructure, VIP Chinese Science and Technology Journals Database, Wanfang database, and clinical trial registration center from their inception to February 28, 2019. The primary outcome measures will be clinical effective rate, functional outcomes, and quality of life. Data that meets the inclusion criteria will be extracted and analyzed using RevMan V.5.3 software. Two reviewers will evaluate the studies using the Cochrane Collaboration risk of bias tool. Publication bias will be assessed by funnel plots, Egger test, and Begg test using the Stata software. Acupoints characteristics will be analyzed by Traditional Chinese Medicine inheritance support system.

RESULTS

This study will analyze the clinical effective rate, functional outcomes, quality of life, daily average number of fecal incontinence, and effective prescriptions of acupuncture for patients with fecal incontinence.

CONCLUSION

Our findings will provide evidence for the effectiveness and potential treatment prescriptions of acupuncture for patients with fecal incontinence.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD42019119680.

A surgical technique for secondary repair of obstetric anal sphincter injuries; sphinctero-vagino-perineoplasty

Objective:

This study was conducted to present the preliminary results of seven patients treated with sphinctero-vagino-perineoplasty for secondary repair of obstetric anal sphincter injuries.

Materials and Methods:

This retrospective study was conducted on the records of seven patients who underwent secondary repair of obstetric anal sphincter injuries at the colorectal surgery unit of a tertiary care center between February 2015 and December 2017.

Results:

All patients with solid stool incontinence were fully recovered at postoperative month 3. The Wexner incontinence score was significantly improved (decreased from 14.12 [range: 8-20] to 2.28 [range: 1-4]). The complication rate was 85.7% (wound infection, abscess, hematoma, detachment).

Conclusion:

Combined repair of anal sphinchters, perineal body, superficial transverse perineal muscles, and bulbospongious muscles, which contribute to anal continence, may improve surgical outcomes in patients with obstetric anal sphincter injuries.

A PASSIVE STATE SIMULATION OF AN ANAL SPHINCTER USING SIMMECHANICS

Nowadays, different mechanical artificial sphincters can be found implanted in human beings, trying to overcome a deficiency in the performance of the natural one. However, they do not take into account the natural anal sphincter’s (AS) dimensions, and autonomous response; they also lack in basic contraction and relaxation properties. In this paper, by addressing the AS behavior, an AS model designed with Matlab/SimMechanics is shown. The model comprises bodies of concentrated mass interconnected by springs. The mass–spring system is arranged in concentric rings where every concentrated mass is interconnected by a spring. Each spring takes specific stiffness, which varies with length, in accordance to an experimental curve. The system described can be loaded or unloaded, describing then the muscle behavior.

Each element that forms the model of rings is subject to displacements caused by forces of traction and compression, when a radial force is applied from the center towards the inner ring. The springs of the inner ring experience forces of traction, whereas the springs that connect the body of the inner ring with the outer ring perpendicularly are submitted to compression forces.The data used in the proposed model corresponded to dimensions of the humanAS: width, height, rigidity, stress, tension, basically obtaining an initial deformation behavior according to the sphincter in the passive state. The model remained stable with some mechanical oscillations due to the elastic elements; by modifying one of the parameters, the behavior became unstable and unmanageable. It was verified that it is a sensitive model when modifying the initial conditions that the concrete data requires in case of reproducing the sphincter muscle with particular dimensions.

Functional and histologic effects after implanting pluripotent stem cells in a murine model with sphincterotomy

INTRODUCTION AND AIMS

Fecal incontinence is a disabling condition with devastating consequences for the patients. Medical and surgical options are not very satisfactory, reason by which regenerative medicine has been considered in this field. In the present research, we analyzed functional and histologic effects after implanting pluripotent stem cells (PSCs) in a murine model with sphincterotomy.

MATERIALS AND METHODS

Female Wistar rats were subjected to sphincterotomy and divided into three groups. Group 1 (control group) was treated with 300μL of balanced saline solution and group 2 (late treatment) and group 3 (early treatment) received 50,000 PSCs resuspended in 300μL of balanced saline solution. All animals were evaluated through high-resolution anorectal manometry 24hours before and after sphincterotomy and every month for three months. Finally, the rats were euthanized and histopathologic sections from the anal canal were obtained.

RESULTS

All groups showed a decrease in resting anal pressure and squeeze anal pressure 24hours after sphincterotomy. At the third month, higher anal pressures in the groups treated with PSCs were detected. Regarding the histologic effects, the microscopic architecture was restored and there was a significant decrease in the inflammatory response in the groups treated with PSCs.

CONCLUSION

PSCs implantation improves anal tone, as well as histologic structure, presenting better regenerative results when implanted as early treatment.

A randomized controlled trial of four different regimes of biofeedback programme in the treatment of faecal incontinence

AIM

Biofeedback is an established, effective and non-invasive treatment for faecal incontinence (FI). The aim was to compare the effectiveness of four different biofeedback treatment regimes.

METHOD

This was a randomized control trial of patients with FI, stratified into two groups (metropolitan and rural) and then randomized into two subgroups (groups 1 and 2 within metropolitan, groups 3 and 4 within rural) with varying face-to-face and telephone biofeedback components. All patients received standardized counselling and education, dietary modification and the use of anti-diarrhoeal medications. Group 1 received four monthly face-to-face biofeedback treatments, groups 2 and 3 received one face-to-face biofeedback followed by telephone biofeedback and group 4 received a one-off face-to-face biofeedback treatment. Primary outcomes were patient-assessed severity of FI and quality of life as assessed by the 36-item Short Form Health Survey and direct questioning of objectives. Secondary outcomes included St Mark's incontinence score, anxiety, depression and anorectal physiology measures (resting, squeeze pressures; isotonic, isometric fatigue times).

RESULTS

Between 2006 and 2012, 351 patients were recruited. One patient died leaving 350 for analysis. 332 (95%) were women. Mean age was 60 (SD = 14). All groups had significant improvements in FI, quality of life, incontinence score and mental status (P < 0.001 each). There were no differences in improvements in FI between groups although patient satisfaction was less with reduced face-to-face contact. There were modest improvements in isotonic and isometric fatigue times suggesting improved sphincter endurance (both P < 0.001).

CONCLUSION

Biofeedback is effective for FI. Although face-to-face and telephone biofeedback is not necessary to improve FI, it is important for patient satisfaction.

Effects of Fermented Milk with Mixed Strains as a Probiotic on the Inhibition of Loperamide-Induced Constipation

To investigate the effects of a single bacterium and a mixture of bacteria as probiotics in loperamide-treated animal models, loperamide (3 mg/kg) was administered to SD rats to induce constipation. The individual lactic acid bacterial doses, Enterococcus faecium (EF), Lactobacillus acidophilus (LA), Streptococcus thermophilus (ST), Bifidobacterium bifidum (BB), Bifidobacterium lactis (BL), Pediococcus pentosaceus (PP), and a mixture of the bacteria were orally administered to loperamide-induced constipated rats at a concentration of 10⁸ CFU/kg for 14 days. The weights and water contents of their stools were found to be significantly higher in PP, CKDB (mixture of 5 strains except PP), and CKDBP (CKDB+PP) groups than in the normal (constipation not induced) and the control (constipation-induced) groups (p<0.05). The intestinal transit ratio was significantly higher in all probiotic-treated groups than in the control group, and was the highest in the CKDBP group (p<0.05). The mucosal length and mucus secretion were significantly improved in all probiotic-treated-groups, as compared to that in the control group, and the CKDBP group was found to be the most effective according to immunohistochemistry (IHC) staining and total short chain fatty acid content analysis (p<0.05). Lastly, PP, CKDB, and CKDBP showed relatively higher Lactobacillus sp. ratios of 61.94%, 60.31% and 51.94%, respectively, compared to the other groups, based on metagenomic analysis.

Hypothesized summative anal physiology score correlates but poorly predicts incontinence severity

AIM

To explore the relationship between such a construct and an existing continence score.

METHODS

A retrospective study of incontinent patients who underwent anal physiology (AP) was performed. AP results and Cleveland Clinic Continence Scores (CCCS) were extracted. An anal physiology score (APS) was developed using maximum resting pressures (MRP), anal canal length (ACL), internal and external sphincter defects and pudendal terminal motor latency. Univariate associations between each variable, APS and CCCS were assessed. Multiple regression analyses were performed.

RESULTS

Of 508 (419 women) patients, 311 had both APS and CCCS measured. Average MRP was 51 mmHg (SD 23.2 mmHg) for men and 39 mmHg (19.2 mmHg) for women. Functional ACL was 1.7 cm for men and 0.7 cm for women. Univariate analyses demonstrated significant associations between CCCS and MRP (P = 0.0002), ACL (P = 0.0006) and pudendal neuropathy (P < 0.0001). The association between APS and CCCS was significant (P < 0.0001) but accounted for only 9.2% of the variability in CCCS. Multiple regression showed that the variables most useful in predicting CCCS were external sphincter defect, pudendal neuropathy and previous pelvic surgery, but only improving the scores predictive ability to 12.5%.

CONCLUSION

This study shows that the ability of AP tests to predict continence scores improves when considered collectively, but that a constructed summation model before and after multiple regression is poor at predicting the variability in continence scores.

Initiative to improve detection of faecal incontinence in primary care: The GIFT Project

BACKGROUND

Faecal incontinence (FI) is a distressing condition with a significant impact on quality of life. The true prevalence of FI is unknown but probably underestimated. Identifying patients affected is of key importance because a significant proportion may improve with conservative treatments, and there are a number of other treatments available.

OBJECTIVES

The aim of our project was to improve detection of FI in our primary care setting.

METHODS

A multidisciplinary working group was created in order to raise awareness and educate health professionals about FI. We designed a simple protocol and organized educational meetings at 7 primary care centres. The usual diagnostic computer-based tools used by nurses were modified, so that FI was systematically asked about. A proactive attitude among doctors and midwives regarding FI was recommended for high-risk patient groups.

RESULTS

The project was implemented in October 2014. Before the intervention, only 250 (<1%) patients with a diagnosis of FI were identified from the primary care register out of a population over 165000 people. Between October 2014 and February 2016, 17370 patients were questioned about anal continence in routine follow-ups. Of those questioned, 829 (4.8%) disclosed suffering from FI. Mean age was 78.5 ± 14 years (16-104), 565 (68.2%) were females, and 264 (31.8%) were males. The percentage of patients with FI increased with age and was higher in women.

CONCLUSION

Our results show that a proactive approach with direct questions on FI may lead to a significant increase in FI detection in primary care.

Managing fecal incontinence in patients with myelomeningocele in Sub-Saharan Africa: Role of antegrade continence enema (ACE)

BACKGROUND

Neural tube defects (NTDs) are among the major causes of sphincter dysfunctions. Fecal incontinence (FI) because of myelomeningocele (MMC) leads to problems with social acceptability and decreased quality of life (QOL), life satisfaction in addition to other morbidities. This is a report of experience with antegrade continence enema (ACE) in the management of FI in patients with MMC in an African set-up.

MATERIALS AND METHOD

A retrospective review of 23 children and young adults with FI because of MMC managed with ACE from October 2008 to September 2015 from African Specialist Hospital. The clinical outcomes have been analyzed.

RESULTS

From October 2008 to September 2015, a total of thirty-two n=32 patients underwent ACE procedure after repair of MMC associated with FI. Available data of 23 (71.87%) patients were reviewed retrospectively. Mean age at which ACE was created was 6.43±3.83years, range (3.5-17.8) years, median 5years. Follow-up after ACE creation was (0.5-6.9) years, median 2.6years. There were full continence in 13 (56.52%), partial continence in 8 (34.78%) and failure in 2 (8.69%). There were 16 (69.56%) complications and 4 (17.39%) minor post ACE surgery revisions. Mean PedQOL⁽™⁾ score before ACE and then 5, 10, and 15months after ACE were 47.86±13.83, range (20.4-66.0) vs 88.34±7.11, range (77.9-98.6); p=0.000, 88.9±6.44 range (76.9-98.5); p=0.000, 89.01±6.50, range (76.9-98.88) p=0.000 respectively. Mean parental/caregiver satisfaction score for 15 (65.21%) patients aged 6years and below using modified visual analogue scale (VAS) 1 to 10 before ACE and after were 3.06±0.79, range (2-4), median 3 vs 8.0±1.30, range (5-10), median 8; (p=0.000) while 8 (34.78%) patients aged above 6years were able to assess their satisfactions score before and after ACE creation with mean of 1.75±0.70, range (1-3), median 2 vs 7.75±1.03, range (6-9) median 8; (p=0.000).

CONCLUSION

ACE has satisfactory outcomes in an African set-up in patients with MMC associated with FI. Multidisciplinary approach to neurogenic FI should be encouraged in such set-ups.

Efficacy of anorectal biofeedback in scleroderma patients with fecal incontinence: a case-control study

OBJECTIVE

To determine whether anorectal biofeedback therapy can improve the symptoms of fecal incontinence (FI) in patients with scleroderma when compared to patients with functional FI, and also whether there is any effect on anorectal physiology or quality of life (QOL). FI in patients with scleroderma is highly prevalent and is associated with significant loss of QOL. Biofeedback has been proven to be an effective treatment for functional FI, but there are no data to support its use in scleroderma.

MATERIALS AND METHODS

13 consecutive female patients (median age 59, IQR 47-65 years) with scleroderma, and 26 age- and parity-matched female patients with functional FI (disease controls, 2:1), underwent biofeedback therapy for management of FI. Fecal incontinence severity index (FISI), anorectal physiology, feeling of control and QOL were collected before and after 6 weeks of biofeedback therapy, with additional scoring repeated at 6-month follow-up.

RESULTS

After biofeedback treatment FISI, feeling of control and QOL significantly improved in both groups (p < 0.005). There was no difference in the degree in improvement in physiology, FISI or QOL between scleroderma patients and functional FI patients. Long-term improvement in FISI and control were seen in both groups and for QOL only in the scleroderma cohort (p < 0.05).

CONCLUSIONS

Patients with scleroderma benefit from biofeedback therapy to the same extent as that achieved in patients with functional FI. There are significant improvements in symptoms, physiology and QOL. Biofeedback is an effective, low-risk treatment option in this patient group.

The Role of Biofeedback Therapy in Functional Proctologic Disorders

Background and Aims:

The question which patients with functional proctologic disorders truly benefit from the biofeedback has not been equivocally resolved. The aim of this study was to assess our results of biofeedback therapy in patients with anal incontinence or constipation.

Material and Methods:

Fifty-two consecutive patients who were treated with biofeedback therapy between January 1998 and March 2002 were studied. Data was collected from our proctologic database.

Results:

Of the twenty-two patients with anal incontinence who underwent biofeedback therapy during the study period, twenty patients had incontinence affecting quality of life. Twelve patients (60 percent) benefited from biofeedback as judged by improvement of incontinence symptoms affecting quality of life; all four patients with partial sphincter defects, three out of four patients after secondary repair, three out of five patients with persistent incontinence after rectal prolapse surgery and two out of seven patients having idiopathic incontinence. Of the thirty patients who underwent biofeedback therapy for constipation, twenty-five had intractable symptoms of constipation. Constipation resolved in sixteen patients (64 percent); in thirteen out of nineteen (68 percent) of those with pelvic floor dysfunction (PFD) and in three out of six (50 percent) having combined PFD and slow transit constipation. In patients with PFD constipation was resolved in ten out of thirteen patients (77 percent) with anismus but in only three out of six (50 percent) having other causes.

Conclusions:

Biofeedback therapy improves incontinence after sphincter repairs and in patients with partial external sphincter defects, but does not improve idiopathic incontinence. Biofeedback is also effective in patients with constipation, especially when anismus is the only cause for symptoms of constipation and difficult evacuation.

Advances in the Surgical Treatment of Fecal Incontinence

Although surgery for fecal incontinence has been shown to be effective, it is still very challenging and sometimes frustrating. Overlapping sphincteroplasty, by far the most common procedure, is effective in patients with sphincter defects; however, recent data suggest that success rates tend to deteriorate over time. A thorough preoperative evaluation incorporates numerous factors, including patient characteristics, severity of incontinence, type and size of the sphincter defect as assessed by physical examination, anal ultrasound, and anorectal physiology studies including anal manometry, electromyography, and pudendal nerve terminal motor latency assessment. The use of these evaluation methods has allowed better patient assignment for a variety of new alternative treatment options. Innovations in the surgical treatment of fecal incontinence range from simple, office-based sphincter augmentation techniques to surgical implantation of mechanical devices. This article reviews 5 alternative surgical treatment options for fecal incontinence: injection of carbon-coated beads in the submucosa of the anal canal, radiofrequency energy delivery, stimulated graciloplasty, artificial bowel sphincter, and sacral nerve stimulation.

Role of diet in fecal incontinence: a systematic review of the literature

INTRODUCTION AND HYPOTHESIS

The objective was to perform a systematic review of the literature to examine original research on the role of diet in fecal incontinence (FI) with a dual focus on dietary differences in FI and dietary treatments for FI.

METHODS

We searched the PubMed and Embase databases for any peer-reviewed original research in English on the role of diet in FI.

RESULTS

We identified 172 unique citations. After title review and exclusion of articles not reporting original research, 9 publications were included in the final review: 4 focused on dietary differences and 5 focused on dietary treatments for FI. Limited evidence indicates that macro- and micronutrient intake does not differ significantly in those with and without FI. However, certain foods were perceived to improve or exacerbate FI symptoms and these varied and were adjusted as part of self-care practices. A high-fiber diet may reduce incontinence frequency.

CONCLUSIONS

Data on the pathogenesis of FI from a dietary perspective are scant. Based on the limited data, dietary differences between those with and without FI provide little insight with the exception of fiber. Further studies are needed to elucidate treatments for FI using fiber and dietary modifications.

Diagnosis and treatment of faecal incontinence: Consensus statement of the Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists

Faecal incontinence is a common and disturbing condition, which leads to impaired quality of life and huge social and economic costs. Although recent studies have identified novel diagnostic modalities and therapeutic options, the best diagnostic and therapeutic approach is not yet completely known and shared among experts in this field. The Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists selected a pool of experts to constitute a joint committee on the basis of their experience in treating pelvic floor disorders. The aim was to develop a position paper on the diagnostic and therapeutic aspects of faecal incontinence, to provide practical recommendations for a cost-effective diagnostic work-up and a tailored treatment strategy. The recommendations were defined and graded on the basis of levels of evidence in accordance with the criteria of the Oxford Centre for Evidence-Based Medicine, and were based on currently published scientific evidence. Each statement was drafted through constant communication and evaluation conducted both online and during face-to-face working meetings. A brief recommendation at the end of each paragraph allows clinicians to find concise responses to each diagnostic and therapeutic issue.

Standard compared with mnemonic counseling for fecal incontinence: a randomized controlled trial

OBJECTIVE

To estimate whether women who underwent mnemonic counseling had better recall of fecal incontinence therapies at 2 months and if mnemonic counseling resulted in greater satisfaction with physician counseling and improvement in quality of life when compared with a group who underwent standard counseling.

METHODS

Counseling-naive women with fecal incontinence were recruited from an academic urogynecology clinic. Women underwent physical examinations, completed the Quality of the Physician-Patient Interaction, recorded fecal incontinence treatment options they recalled, and completed the Fecal Incontinence Severity Index and Manchester Health Questionnaire immediately after counseling and again at 2 months.

RESULTS

Ninety women consented to participate, were randomized, and completed baseline questionnaires. At baseline, women did not differ in age, ethnicity, education, Fecal Incontinence Severity Index, or Manchester Health Questionnaire scores. After counseling, the mnemonic group reported higher satisfaction on Quality of the Physician-Patient Interaction (66.4±6.5 compared with 62.2±10.7, P=.03). Ninety percent (81/90) of women followed up at 2 months. Our primary endpoint, 2-month recall of fecal incontinence treatments, was not different between groups (2.3±1.6 mnemonic counseling compared with 1.8±1.0 standard counseling; P=.08). Secondary endpoints for the mnemonic group reported greater improvement on total Manchester Health Questionnaire (P=.02), emotional (P=.03), sleep (0.045), role limitations (P<.01), and physical limitations (P=.04) when compared with the standard group.

CONCLUSION

Fecal incontinence counseling with a mnemonic aid did not improve recall at 2 months but improved patient satisfaction and quality of life at 2 months.

Is electromyography a predictive test of patient response to biofeedback in the treatment of fecal incontinence?

AIM

Biofeedback is effective in more than 70% of patients with fecal incontinence. However, reliable predictors of successful treatment have not been identified. The aim was to identify clinical variables and diagnostic tests, particularly electromyography, that could predict a successful outcome.

METHODS

We included 135 consecutive women with fecal incontinence treated with biofeedback. Clinical evaluation, manometry, ultrasonography, electromyography, and pudendal nerve terminal motor latency were performed before therapy. Treatment outcome was assessed using a symptoms diary, Wexner incontinence score and the patient's subjective perception.

RESULTS

According to the symptoms diaries, 106 (78.5%) women had a good clinical result and 29 (21.5%) had a poor result. There were no differences in age, severity and type of fecal incontinence. Maximum resting pressure (39.3 ± 19.1 mmHg vs. 33.7 ± 20.2 mmHg; P = 0.156) and maximum squeeze pressure (91.8 ± 33.2 mmHg vs. 79.8 ± 31.2 mmHg; P = 0.127) were higher in patients having good clinical outcome although the difference was not significant. There were no differences in the presence of sphincter defects or abnormalities in electromyographic recordings. Logistic regression analysis found no independent predictive factor for good clinical outcome.

CONCLUSIONS

Biofeedback is effective in more than 75% of patients with fecal incontinence. Clinical characteristics of patients and results of baseline tests have no predictive value of response to therapy. Specifically, we found no association between severity of electromyographic deficit and clinical response.

Patients' experience compared with physicians' recommendations for treating fecal incontinence: a qualitative approach

INTRODUCTION AND HYPOTHESIS

Using qualitative methods, we compared physician-recommended treatment options for fecal incontinence to patient knowledge of treatment options. Our hypothesis was that physician recommendations were not being communicated well to patients and that this impaired patients' ability to cope with fecal incontinence.

METHODS

Cognitive interviews were conducted with physicians who routinely care for women with fecal incontinence. Physicians were asked to describe their typical nonsurgical treatment recommendations and counseling for fecal incontinence. Women with bothersome fecal incontinence were recruited to participate in focus groups and asked about personal experience with fecal incontinence symptoms and treatment options. For both physician interviews and patient focus groups, qualitative data analysis was performed using grounded-theory methodology.

RESULTS

Physicians identified several barriers patients face when seeking treatment: lack of physician interest toward fecal incontinence, and patient embarrassment in discussing fecal incontinence. Physicians universally recommended fiber and pelvic floor exercise; they felt the majority (approximately 70-80 %) of patients will improve with these therapies. Collectively, patients were able to identify all treatment recommendations given by physicians, although many had discovered these treatments through personal experience. Three concepts emerged regarding treatment options that physicians did not identify but that patients felt were important in their treatment: hope for improvement, personal effort to control symptoms, and encouragement to go on living life fully.

CONCLUSIONS

Whereas physicians had treatment to offer women with fecal incontinence, women had already found the best treatments through personal research and effort. Women want to hear a message of hope and encouragement and perceive personal effort from providers.

Early functional results of biofeedback and its impact on quality of life of patients with anal incontinence

CONTEXT

Biofeedback has been used successfully in the treatment of fecal incontinence, working mainly on rehabilitation of the sphincter muscle. However, there are few studies presenting objective results of biofeedback, in terms of functional results and those related to the quality of life.

OBJECTIVES

The aims of this study was to evaluate the immediate results of biofeedback in the treatment of fecal incontinence and its impact on the quality of life of patients by using validated questionnaires, correlating the results with those related to functional parameters of quality of life and clinical variables.

METHODS

We analyzed and compared the results of biofeedback in 52 patients with fecal incontinence before the start of the sessions and immediately after the end of them, by applying validated questionnaires assessing the degree of intensity of fecal incontinence (FISI - Fecal Incontinence Severity Index) and evaluation of quality of life related to fecal incontinence (FIQL - Faecal Incontinence Quality of Life Scale) as compared to clinical variables (age, onset of symptoms, etiology of the fecal incontinence, number of sessions of biofeedback and number and types of deliveries).

RESULTS

The evaluation of the results of FISI showed a significant increase in the number of individuals who had low severity scores of symptoms before and after the biofeedback (from 48.1 to 65.4%) with P = 0.004. There was significant improvements in domains of the FIQL, behavior (P = 0.008), depression (P = 0.006) and embarrassment (P = 0.008) after biofeedback. There was no significant correlation between the improvement of functional parameters evaluated by FISI and the improvement of quality of life. Positive correlation was found between the improvements of the domains of FIQL. There was no significant correlation between the results obtained using the FISI and FIQL with clinical variables assessed.

CONCLUSIONS

Biofeedback has proven to be an effective therapy in the treatment of fecal incontinence, improving symptoms and/or quality of life for most patients, regardless of clinical presentation of this functional disorder.

Peristeen anal irrigation as a substitute for the MACE procedure in children who are in need of reconstructive bladder surgery

INTRODUCTION

We evaluate the efficacy of the Peristeen (Coloplast A/S, Kokkedal, Denmark) transanal irrigation (TAI) system, as a stool cleansing mechanism, to gain stool continence in children who need reconstructive bladder surgery and have fecal incontinence.

METHODS

We prospectively evaluated children with neuropathic bladder and bowel dysfunction who were intended for reconstructive bladder surgery and the Malone antegrade continence enema (MACE) procedure. All patients were started on the Peristeen TAI system at least 3 months before surgery to assess their response. Each patient's bowel function, frequency of using the system, satisfaction (and that of their parents) and diaper independency were evaluated before and after reconstructive surgery.

RESULTS

We included 18 patients (11 female, 7 male) who were evaluated from April 2006 to the present. The mean age of the group was 7.6 years (range: 4-15). Fifteen patients (83.3%) showed complete dryness from stools. Of the 15 patients, 8 (53.3%) were able to be diaper-free, while 6 continued wearing diapers due to fear of soiling and 1 due to urinary incontinence. The patients underwent reconstructive bladder surgery and continued to use the Peristeen TAI system with the same results postoperatively. The main limitation of this study is the small number of patients included, although this is a very specific patient group.

CONCLUSION

Our initial results suggest that the Peristeen TAI system is a successful conservative substitute for the MACE procedure in children who require reconstructive bladder surgery.

Technique of functional and motility test: how to perform biofeedback for constipation and fecal incontinence

Biofeedback therapy is an instrument-based learning process centered on operant conditioning. The goal of biofeedback therapy in defecatory disorders is to strengthen the pelvic floor muscles, retrain rectal sensation and coordinate pelvic floor muscles during evacuation. Biofeedback therapy, in a broader sense, includes education, counseling, and diaphragmatic muscle training as well as exercise, sensory, and coordination training. For dyssynergic defecation, biofeedback therapy is a well-known and useful treatment option that had response rates of approximately 70-80% in randomized controlled trials. Biofeedback therapy for dyssynergic defecation consists of improving the abdominal push effort together with biofeedback technique-guided pelvic floor relaxation followed by simulated defecation and/or sensory training. For fecal incontinence, the results of a randomized controlled trial, which had a response rate of 76%, indicated that biofeedback therapy is useful in selected patients who fail to respond to conservative treatment and that training to enhance rectal discrimination of sensation may be helpful in reducing fecal incontinence. The focus of biofeedback therapy for fecal incontinence is on exercising external sphincter contractions under instant feedback, either alone or synchronously with rectal distension and/or sensory training. Biofeedback therapy is a safe treatment that may produce durable improvement beyond the active treatment period; however, a well-designed study to establish a standard protocol for biofeedback therapy is needed. This review discusses the technique of biofeedback therapy to achieve the goal and clinical outcomes for constipation and fecal incontinence.

Outcome of antegrade continent enema (ACE) procedures in children and young adults

OBJECTIVE

Intractable incontinence affects a large number of children and young adults in the US. The goal of this study is to evaluate the long-term outcomes of surgical access for administration of antegrade continence enemas (ACE) in affected children and young adults.

METHODS

Patients who underwent surgical procedure to enable administration of ACE from 1994 to 2011 were retrospectively reviewed. Data collected included patient demographics, primary diagnosis, surgical technique, conduit used, complications, follow-up duration, and social continence.

RESULTS

Sixty eighty patients underwent surgery to enable ACE; mean follow up was 61 months. Enteral conduit (EC) was performed in 19 patients, tube cecostomy catheters (CC) in 49. Meningomyelocele was diagnosed in 60% of patients. Mean age was 11 (1.67-53) years. Complications included tube dislodgement (43%), granulation tissue (46%), site infection (13%), leakage (32%), break in the tube (6%) and tract stenosis (6%). Complete social continence was achieved in 68%, partial continence was achieved in 29%, and no benefit was achieved in 3% of patients. The rate of complications and incontinence resolution following CC was 78% and 66%, and following EC 89% and 74%. The differences were not statistically significant. CC patients developed granulation tissue more frequently (53%) and leaks of fecal material less frequently (20%) compared to EC patients (26% and 53%) (p < 0.05 and < 0.01). Although children 7 years or younger developed more overall complications (94%) than older patients (69%; p < 0.05), there was not a significant difference in the frequency of any one complication or in the rate of continence, between the two groups. Multivariate analysis showed that EC is three times more likely to be complicated by fecal leakage. CC patients are at greater risk to develop granulation tissue (p < 0.05).

CONCLUSIONS

Most patients achieved social continence and improved hygiene with the aid of ACE. Younger children also benefited greatly from institution of ACE. CC was associated with fewer major complications such as leak of fecal contents than EC but required regular tube changes.

Drug treatment for faecal incontinence in adults

BACKGROUND

Faecal incontinence (leakage of bowel motions or stool) is a common symptom which causes significant distress and reduces quality of life.

OBJECTIVES

To assess the effects of drug therapy for the treatment of faecal incontinence. In particular, to assess the effects of individual drugs relative to placebo or other drugs, and to compare drug therapy with other treatment modalities.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register of Trials, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and MEDLINE in process, and handsearching of journals and conference proceedings (searched 21 June 2012) and the reference lists of relevant articles.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials were included in this systematic review.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened abstracts, extracted data and assessed risk of bias of the included trials.

MAIN RESULTS

Sixteen trials were identified, including 558 participants. Eleven trials were of cross-over design. Eleven trials included only people with faecal incontinence related to liquid stool (either chronic diarrhoea, following ileoanal pouch or rectal surgery, or due to use of a weight-reducing drug). Two trials were amongst people with weak anal sphincters, one in participants with faecal impaction and bypass leakage, and one in geriatric patients. In one trial there was no specific cause for faecal incontinence.Seven trials tested anti-diarrhoeal drugs to reduce faecal incontinence and other bowel symptoms (loperamide, diphenoxylate plus atropine, and codeine). Six trials tested drugs that enhance anal sphincter function (phenylepinephrine gel and sodium valproate). Two trials evaluated osmotic laxatives (lactulose) for the treatment of faecal incontinence associated with constipation in geriatric patients. One trial assessed the use of zinc-aluminium ointment for faecal incontinence. No studies comparing drugs with other treatment modalities were identified.There was limited evidence that antidiarrhoeal drugs and drugs that enhance anal sphincter tone may reduce faecal incontinence in patients with liquid stools. Loperamide was associated with more adverse effects (such as constipation, abdominal pain, diarrhoea, headache and nausea) than placebo. However, the dose may be titrated to the patient's symptoms to minimise side effects while achieving continence. The drugs acting on the sphincter sometimes resulted in local dermatitis, abdominal pain or nausea. Laxative use in geriatric patients reduced faecal soiling and the need for help from nurses.Zinc-aluminium ointment was associated with improved quality of life, with no reported adverse effects. However, the observed improvement in quality of life was seen in the placebo group as well as the treatment group.It should be noted that all the included trials in this review had small sample sizes and short duration of follow-up. 'Risk of bias' assessment was unclear for most of the domains as there was insufficient information. There were no data suitable for meta-analysis.

AUTHORS' CONCLUSIONS

The small number of trials identified for this review assessed several different drugs in a variety of patient populations. The focus of most of the included trials was on the treatment of diarrhoea, rather than faecal incontinence. There is little evidence to guide clinicians in the selection of drug therapies for faecal incontinence. Larger, well-designed controlled trials, which use the recommendations and principles set out in the CONSORT statement, and include clinically important outcome measures, are required.

Biofeedback and/or sphincter exercises for the treatment of faecal incontinence in adults

BACKGROUND

Faecal incontinence is a particularly embarrassing and distressing condition with significant medical, social and economic implications. Anal sphincter exercises (pelvic floor muscle training) and biofeedback therapy have been used to treat the symptoms of people with faecal incontinence. However, standards of treatment are still lacking and the magnitude of alleged benefits has yet to be established.

OBJECTIVES

To determine the effects of biofeedback and/or anal sphincter exercises/pelvic floor muscle training for the treatment of faecal incontinence in adults.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 24 January 2012) which contains trials from searching CENTRAL, MEDLINE and handsearching of conference proceedings; and the reference lists of relevant articles.

SELECTION CRITERIA

All randomised or quasi-randomised trials evaluating biofeedback and/or anal sphincter exercises in adults with faecal incontinence.

DATA COLLECTION AND ANALYSIS

Two review authors assessed the risk of bias of eligible trials and two review authors independently extracted data from the included trials. A wide range of outcome measures were considered.

MAIN RESULTS

Twenty one eligible studies were identified with a total of 1525 participants. About half of the trials had low risk of bias for randomisation and allocation concealment.One small trial showed that biofeedback plus exercises was better than exercises alone (RR for failing to achieve full continence 0.70, 95% CI 0.52 to 0.94).One small trial showed that adding biofeedback to electrical stimulation was better than electrical stimulation alone (RR for failing to achieve full continence 0.47, 95% CI 0.33 to 0.65).The combined data of two trials showed that the number of people failing to achieve full continence was significantly lower when electrical stimulation was added to biofeedback compared against biofeedback alone (RR 0.60, 95% CI 0.46 to 0.78).Sacral nerve stimulation was better than conservative management which included biofeedback and PFMT (at 12 months the incontinence episodes were significantly fewer with sacral nerve stimulation (MD 6.30, 95% CI 2.26 to 10.34).There was not enough evidence as to whether there was a difference in outcome between any method of biofeedback or exercises. There are suggestions that rectal volume discrimination training improves continence more than sham training. Further conclusions are not warranted from the available data.

AUTHORS' CONCLUSIONS

The limited number of identified trials together with methodological weaknesses of many do not allow a definitive assessment of the role of anal sphincter exercises and biofeedback therapy in the management of people with faecal incontinence. We found some evidence that biofeedback and electrical stimulation may enhance the outcome of treatment compared to electrical stimulation alone or exercises alone. Exercises appear to be less effective than an implanted sacral nerve stimulator. While there is a suggestion that some elements of biofeedback therapy and sphincter exercises may have a therapeutic effect, this is not certain. Larger well-designed trials are needed to enable safe conclusions.

The Bristol Stool Form Scale: its translation to Portuguese, cultural adaptation and validation

The Bristol Stool Form Scale is used for describing feces. The objective of this research was its translation, cultural adaptation and validation for Brazil. The methodology was translation, back-translation and discussion. Validation involved 85 nurses, 80 doctors, and 80 patients, who correlated images of seven types of feces with the descriptions. Results: there was a difference in sex distribution, with males predominating among the doctors and females among nurses and patients. In relation to concordance between definitions and pictures, the highest percentage was in type 5 in all three groups and the lowest was in types 6 and 7 for the doctors, in type 3 for the nurses, and type 6 for the patients. The general Kappa index was 0.826. Conclusion: the scale demonstrated high reliability for all the groups studied.

Prevalence of anal incontinence among Norwegian women: a cross-sectional study

OBJECTIVE

Anal incontinence (AI) is a symptom associated with age, bowel symptoms and obstetric injuries. Primary aim of the study was to establish the prevalence of AI among women and secondarily to evaluate the impact on daily life and conditions associated with AI.

DESIGN

A cross-sectional study.

SETTING

Participants attended research stations located in different parts of Nord-Trøndelag county, Norway. Data were collected through interviews, questionnaires and clinical examinations.

PARTICIPANTS

In total, 40 955 community-dwelling women aged 30 years and older were invited. A total of 25 037 women participated, giving a participation rate of 61.1%.

PRIMARY AND SECONDARY OUTCOME MEASURES

Fecal incontinence and flatal incontinence was defined as involuntary loss of feces and flatus weekly or more, respectively. AI was defined as the involuntary loss of feces and/or flatus weekly or more. Urgency was defined as the inability to defer defecation for 15 min. Statistical methods included prevalence estimates and logistic regression analysis.

RESULTS

Questions about AI were completed by 20 391 (82.4%) women. Among the 20 391 women, AI was reported by 19.1% (95% CI 18.6% to 19.7%) and fecal incontinence was reported by 3.0% (95% CI 2.8% to 3.2%). Urgency was experienced by 2586 women (12.7%, 95% CI 12.2 to 13.1). Impact on daily life was stated by 794 (26.0%, 95% CI 24.4 to 27.5) women with AI. In bivariate age-adjusted analysis of AI, OR and CI for urgency (OR 3.19, 95% CI 2.92 to 3.49) and diarrhoea (OR 3.81, 95% CI 3.32 to 4.38) revealed strongest associations with AI.

CONCLUSIONS

AI affects one in five women older than 30 years. Strongest associated symptoms are urgency and diarrhoea.

TRIAL REGISTRATION NUMBER

The study was approved by the Regional Committee for Medical and Health Research Ethics (No. 2009/1214) and followed the Declaration of Helsinki.

Treatment of fecal incontinence - review of observational studies (OS) and randomized controlled trials (RCT) related to injection of bulking agent into peri-anal tissue

PURPOSE: Novel treatments are needed to augment medical therapy for fecal incontinence. METHODS: Medline and Google search (fecal incontinence and injection treatment), English publications. RESULTS: Twenty-two observational studies and 4 randomized controlled trials were identified. OS mostly with limited sample sizes reported promising results. Repeated injection was necessary in some patients. Effect on anal sphincter pressures was highly variable. Significant improvements in the length of anal high-pressure zone, asymmetry index and maximum tolerable rectal volume were suggested. Four randomized controlled trials (n=176) revealed: 1. Short-term benefits from injection of Bioplastique under ultrasound guidance compared with digital guidance; 2. Silicone biomaterial (PTQ) provided some advantages and was safer than carbon-coated beads (Durasphere); 3. PTQ did not demonstrate clinical benefit compared to control injection of saline; 4. There was significant improvement at 6 weeks post injection, but no difference between Bulkamid and Permacol. A 2010 Cochrane review, however, noted that these data were inconclusive due to limited number and methodological weaknesses. CONCLUSION: Further studies are warranted to assess patient-centered outcomes (e.g. adequate relief) in addition to the attenuation of severity of incontinence symptoms in ambulatory patients. In nursing home residents, cost-effectiveness studies combining injection treatment and prompted voiding (to mitigate constraints of immobility and dementia) in preventing peri-anal skin complications deserves to be considered.

Local transdermal delivery of phenylephrine to the anal sphincter muscle using microneedles

We propose pretreatment using microneedles to increase perianal skin permeability for locally targeted delivery of phenylephrine (PE), a drug that increases resting anal sphincter pressure to treat fecal incontinence. Microneedle patches were fabricated by micromolding poly-lactic-acid. Pre-treatment of human cadaver skin with microneedles increased PE delivery across the skin by up to 10-fold in vitro. In vivo delivery was assessed in rats receiving treatment with or without use of microneedles and with or without PE. Resting anal sphincter pressure was then measured over time using water-perfused anorectal manometry. For rats pretreated with microneedles, topical application of 30% PE gel rapidly increased the mean resting anal sphincter pressure from 7±2 cm H(2)O to a peak value of 43±17 cm H(2)O after 1 h, which was significantly greater than rats receiving PE gel without microneedle pretreatment. Additional safety studies showed that topically applied green fluorescent protein-expressing E. coli penetrated skin pierced with 23- and 26-gauge hypodermic needles, but E. coli was not detected in skin pretreated with microneedles, which suggests that microneedle-treated skin may not be especially susceptible to infection. In conclusion, this study demonstrates local transdermal delivery of PE to the anal sphincter muscle using microneedles, which may provide a novel treatment for fecal incontinence.

Approach to fecal incontinence and constipation in older hospitalized patients

Although constipation and fecal incontinence are commonly encountered in older hospitalized patients, there is a paucity of clinical studies in this field. In this article we discuss the approach to and management of patients with these problems based on evidence and studies performed on patients in the ambulatory care setting, nursing home setting, and our experience. Our recommendations are applicable to older hospitalized patients. Successful management of these patients depends on identifying and treating underlying cause(s), such as infection, dietary factors, medication, or immobility-induced incontinence, constipation, or fecal impaction. For a hospitalized patient, a digital rectal examination should be performed to rule out fecal impaction and overflow incontinence. If there is no impaction but a weak anal sphincter, stool softeners or laxatives should be discontinued, as they cause diarrhea/fecal incontinence. In a patient with diarrhea/incontinence and suspected infection, management includes checking stool for Clostridium difficile toxin, E0157, ova and parasites, and culture. If the patient is on enteral nutrition, osmotic diarrhea-induced incontinence should be considered. Nursing care includes use of absorbent pads, special undergarments, anal hygiene, and skin care. Medications such as loperamide or diphenoxylate/atropine are useful for diarrhea with incontinence. Laxatives (eg, polyethylene glycol, lactulose), secretagogues (eg, lubiprostone), enemas, suppositories, and timed toileting assistance may be effective for constipation. Despite appropriate management, older hospitalized patients may remain incontinent because of dementia, immobility, or comorbid issues. Treatment should be tailored to the underlying mechanism(s) and needs of each patient.

Survey of geriatricians on the effect of fecal incontinence on nursing home referral

OBJECTIVES

Determine the effect of fecal incontinence (FI) on healthcare providers' decisions to refer patients for nursing home (NH) placement.

DESIGN

Survey.

SETTING

Questionnaires were e-mailed to participants' homes or offices. Participants could also volunteer at the 2008 American Geriatric Society annual meeting in Washington, DC.

PARTICIPANTS

Two thousand randomly selected physician members and all 181 nurse practitioner members of the American Geriatrics Society were surveyed.

MEASUREMENTS

The survey presented a clinical scenario of a 70-year-old woman ready for discharge from a hospital and asked about the likelihood of making a NH referral if the patient had no incontinence, urinary incontinence (UI) alone, or FI. Subsequent questions modified the clinical situation to include other conditions that might affect the decision to refer. A second survey of respondents to Survey 1 addressed possible moderators of the decision to refer (e.g., family caregiver presence, diarrhea or constipation, other physical or psychiatric limitations). Significance of differences in the relative risk (RR) for NH referral was tested using the chi-square test.

RESULTS

Seven hundred sixteen members (24.7% response rate) completed the first survey, and 686 of the 716 (96%) completed the second. FI increased the likelihood of NH referral (RR=4.71, P<.001) more than UI did (RR=1.90, P<.001). Mobility restrictions, cognitive decline, and multiple chronic illnesses increased the likelihood of NH referral more than FI alone (P<.001 for each), but in all scenarios, adding FI further increased the likelihood of referral (P<.001). Having family caregivers willing to help with toileting attenuated the likelihood of referral.

CONCLUSION

FI increases the probability that geriatricians will refer to a NH. More-aggressive outpatient treatment of FI might delay or prevent NH referral, improve quality of life, and reduce healthcare costs.