Six years of experience with sacral nerve stimulation for fecal incontinence

Faecal incontinence-a comprehensive review

Introduction

Faecal incontinence (FI) is a distressing and often stigmatizing condition characterised as the recurrent involuntary passage of liquid or solid faeces. The reported prevalence of FI exhibits considerable variation, ranging from 7 to 15% in the general population, with higher rates reported among older adults and women. This review explores the pathophysiology mechanisms, the diagnostic modalities and the efficiency of treatment options up to date.

Methods

A review of the literature was conducted to identify the pathophysiological pathways, investigation and treatment modalities.

Result and discussion

This review provides an in-depth exploration of the intricate physiological processes that maintain continence in humans. It then guides the reader through a detailed examination of diagnostic procedures and a thorough analysis of the available treatment choices, including their associated success rates. This review is an ideal resource for individuals with a general medical background and colorectal surgeons who lack specialized knowledge in pelvic floor disorders, as it offers a comprehensive understanding of the mechanisms, diagnosis, and treatment of faecal incontinence (FI).

Sacral nerve modulation for patients with fecal incontinence: long-term outcome and effects on sexual function

Sacral nerve modulation has become an established treatment for fecal and urinary incontinence, and sexual disorders. The objective of this study was to evaluate the long-term outcome of sacral neuromodulation in patients with fecal or combined fecal and urinary incontinence (double incontinence), assessing its safety, efficacy, and impact on quality of life and sexual function. This was a multicentric, retrospective, cohort study including patients with fecal or double incontinence who received sacral neuromodulation at seven European centers between 2007 and 2017 and completed a 5-year follow-up. The main outcome measures included improvements of incontinence symptoms and quality of life compared with baseline, evaluated using validated tools and questionnaires at 1-, 6-, 12-, 36- and 60-month follow-up. 108 (102 women, mean age 62.4 ± 13.4 years) patients were recruited, of whom 88 (81.4%) underwent definitive implantation of the pacemaker. Patients' baseline median Cleveland Clinic Incontinence Score was 15 (10-18); it decreased to 2 (1-4) and 1 (1-2) at the 12- and 36-month follow-up (p < 0.0001), remaining stable at the 5-year follow-up. Fecal incontinence quality of life score improved significantly. All patients with sexual dysfunction (n = 48) at baseline reported symptom resolution at the 5-year follow-up. The study was limited by the retrospective design and the relatively small patient sample. Sacral nerve modulation is an effective treatment for fecal and double incontinence, achieving satisfactory long-term success rates, with resolution of concomitant sexual dysfunction.

[Sacral Neuromodulation for Fecal Incontinence and Constipation: Evidence, Programming and Long-term Management]

BACKGROUND

Over the last two decades, sacral neuromodulation (SNM) has established its role in the treatment of functional pelvic organ-/pelvic floor disorders. Even though the mode of action is not fully understood, SNM has become the preferred surgical treatment of fecal incontinence.

METHODS AND RESULTS

A literature search was carried out on programming sacral neuromodulation and long-term outcomes in treating fecal incontinence and constipation.Sacral neuromodulation was found to be successful in the long term. Over the years, the spectrum of indications has expanded, and now includes patients presenting with anal sphincter lesions. The use of SNM for low anterior resection syndrome (LARS) is currently under clinical investigation. Findings of SNM for constipation are less convincing. In several randomised crossover studies, no success was demonstrated, even though it is possible that subgroups may benefit from the treatment. Currently the application cannot be recommended in general.The pulse generator programming sets the electrode configuration, amplitude, pulse frequency and pulse width. Usually pulse frequency and pulse width follow a default setting (14 Hz, 210 s), while electrode configuration and stimulation amplitude are adjusted individually to the patient need and perception of stimulation.Despite low infection rates and few electrode-/pulse generator dysfunctions, up to 65% of patients require surgical reintervention during long term follow-up - in 50% of cases because of battery depletion, which is an expected event. At least one reprogramming is necessary in about 75% of the patients during the course of the treatment, mostly because of changes in effectiveness, but rarely because of pain. Regular follow-up visits appear to be advisable.

CONCLUSION

Sacral neuromodulation can be considered to be a safe and effective long-term therapy of fecal incontinence. To optimise the therapeutic effect, a structured follow-up regime is advisable.

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.

Sacral neuromodulation with the InterStim™ system for faecal incontinence: results from a prospective French multicentre observational study

AIM

The aim of this work was to evaluate the effectiveness, patient satisfaction and quality of life (QoL) and the safety of sacral neuromodulation (SNM) with the InterStim^TM system for the treatment of faecal incontinence (FI) and establish whether results published predominantly by expert sites are generalisable.

METHOD

This is a prospective, multicentre, observational study that invited all French sites treating FI with the InterStim™ system to enrol subjects indicated for an SNM therapy evaluation. Data were collected at three follow-up visits within 1 and 15 months. Therapeutic effectiveness was evaluated by the reduction in leakages per week and improvements over time in the ability to defer defaecation and QoL (as measured with the Faecal Incontinence Quality of Life score). Safety was assessed through reported adverse events.

RESULTS

A total of 221 subjects with a mean age of 62.1 years were tested (184 women) and 178 received a permanent implant. For all implanted subjects with diary data at baseline and follow-up, a reduction in leakage of more than 50% was observed in 80%, 76% and 83% at 1-3, 4-8 and 9-15 months, respectively. The mean number of leakage episodes and urgency improved significantly compared with the baseline (p < 0.0001). Subjects showed improvements in QoL and time to defer defaecation and were generally satisfied with their therapy. The main device-related adverse event was the requirement to undertake reprogramming (in 52% of subjects with actions following an event). The rates of infection (in 6% of subjects) and surgical revision (in 10% of subjects) were in agreement with literature reports.

CONCLUSION

This study confirms the clinical effectiveness, safety and positive effect of SNM on QoL as well as high patient satisfaction for the treatment of FI in real-life.

Changing paradigm of sacral neuromodulation and external anal sphincter repair for faecal incontinence in specialist centres

AIM

The aim of this study was to determine whether the paradigm of surgical intervention for faecal incontinence (FI) has changed between 2000 and 2013.

METHOD

This was a multi-centre retrospective study of patients who had undergone either sacral neuromodulation (SNM) or delayed sphincter repair or sphincteroplasty (SR) as a primary surgical intervention for FI in five centres in Europe and one in the United States. The flow of patients according to the intervention, sustainability of the treatment at a minimum follow-up of 5 years, complications and requirement for further interventions were recorded.

RESULTS

A total of 461 patients (median age 56 years, range 24-90 years, 41 men) had either SNM or SR as an index operation during the study period [SNM 284 (61.6%), SR 177 (38.4%)]. Among SNM patients, there were 169 revisional operations (change of battery and/or lead, re-siting or removal). At the time of last follow-up 203 patients (71.4%) continued to use SNM. Among SR patients, 30 (16.9%) had complications, most notably wound infection (22, 12.4%). During follow-up 32 patients (18.1%) crossed over to SNM. Comparing two 4-year periods (2000-2003 and 2007-2010), the proportion of patients operated on who had a circumferential sphincter defect of less than 90° was 48 (68%) and 45 (46%), respectively (P = 0.03), while those who had SNM as the primary intervention increased from 29% to 89% (P < 0.05).

CONCLUSION

The paradigm of surgical intervention for FI has changed with increasing use of SNM.

Translumbosacral Neuromodulation Therapy for Fecal Incontinence: A Randomized Frequency Response Trial

INTRODUCTION

Treatments for fecal incontinence (FI) remain unsatisfactory because they do not remedy the underlying multifactorial dysfunction(s) including anorectal neuropathy. The aim of this study was to investigate the optimal dose frequency, clinical effects, and safety of a novel treatment, translumbosacral neuromodulation therapy (TNT), aimed at improving neuropathy.

METHODS

Patients with FI were randomized to receive 6 sessions of weekly TNT treatments consisting of 600 repetitive magnetic stimulations over each of 2 lumbar and 2 sacral sites with either 1, 5, or 15 Hz frequency. Stool diaries, FI severity indices, anorectal neurophysiology and sensorimotor function, and quality of life were compared. Primary outcome measure was the change in FI episodes/week. Responders were patients with ≥50% decrease in weekly FI episodes.

RESULTS

Thirty-three patients with FI participated. FI episodes decreased significantly (∆ ±95% confidence interval, 4.2 ± 2.8 (1 Hz); 2 ± 1.7 (5 Hz); 3.4 ± 2.5 (15 Hz); P < 0.02) in all 3 groups when compared with baseline. The 1 Hz group showed a significantly higher (P = 0.04) responder rate (91 ± 9.1%) when compared with the 5 Hz group (36 ± 18.2%) or 15 Hz (55 ± 18.2%); no difference was found between the 5 and 15 Hz groups (P = 0.667). Anal neuropathy, squeeze pressure, and rectal capacity improved significantly only in the 1 Hz (P < 0.05) group compared with baseline, but not in other groups. Quality of life domains improved significantly (P < 0.05) with 1 and 5 Hz groups. No device-related serious adverse events were noted.

DISCUSSION

TNT significantly improves FI symptoms in the short term, and the 1 Hz frequency was overall better than 5 and 15 Hz. Both anorectal neuropathy and physiology significantly improved, demonstrating mechanistic improvement. TNT is a promising, novel, safe, efficacious, and noninvasive treatment for FI (see Visual Abstract, Supplementary Digital Content 3, http://links.lww.com/AJG/B598).

Improved longevity and efficacy of sacral nerve stimulation by simple adjustments at follow-up

AIM

Sacral nerve stimulation (SNS) for faecal incontinence (FI) at subsensory amplitudes as low as 50% of the sensory threshold has been found to be effective at 3 months' follow-up. Furthermore, alternative pacemaker settings may improve functional outcome in patients with suboptimal treatment efficacy. In this work we aim to explore if sub-sensory stimulation as low as 50% of sensory threshold is effective at 1-year follow-up. We also aimed to investigate if 31 Hz (frequency) or 90 µs (pulse width) stimulation improved treatment efficacy in dissatisfied patients.

METHOD

All patients in whom the stimulation was effective in controlling FI (satisfied group) were encouraged to have the stimulation amplitude reduced. Those in whom the device was less effective (dissatisfied group) were offered alternative frequency settings or pulse width (31 Hz or 90 µs). Patients were follow-up after 12 months and evaluated by a visual analogue scale (VAS) for patient satisfaction, the Cleveland Clinic Continence Score (CCCS), Rockwood Faecal Incontinence Quality of Life Scale (QoL) and a bowel habit diary.

RESULTS

Two hundred and nineteen patients were contacted, with a response rate of 71% (n = 155). Those who were successfully contacted comprised 110 (71%) patients classed as satisfied and 45 (29%) as dissatisfied. Seventy-five (68%) of the satisfied patients agreed to have their stimulation amplitude reduced. At 1-year follow-up the median amplitude had reduced from 1.5 V [interquartile range (IQR) 0.85-2.0 V] to 0.75 V (IQR 0.45-1.4 V) (P-value < 0.001) representing an overall reduction of 39% (6.6-62.5%). There were no significant differences in VAS, CCCS or QoL despite subsensory stimulation at 1-year follow-up. In 28% of the dissatisfied patients alternative pacemaker settings improved VAS to satisfactory levels.

CONCLUSION

Subsensory stimulation is as effective as stimulation at or above the sensory threshold. High-frequency stimulation (31 Hz) can improve functional outcome in patients with loss of efficacy.

Outcomes of treatment of faecal incontinence with sacral nerve stimulation - a Finnish multicentre study

AIM

The aim of this multicentre study is to report the results of sacral nerve stimulation (SNS) treatment for faecal incontinence (FI) in Finland and determine factors that could influence SNS treatment outcomes.

METHOD

This is a national multicentre study, involving all patients tested for SNS implantation in Finland from 1999 to 2017. Data were collected retrospectively from electronic patient archives and analysed for possible effects on treatment outcome.

RESULTS

Of the 432 patients with FI tested for SNS, 365 were women. Three hundred and thirteen (72.5%) of the tested patients advanced to permanent implantation of a stimulator. A successful final treatment outcome, with subjective alleviation of FI, was reported by 59.3% of the patients at the end of follow-up (mean 2.4 years, range 8 days to 13.3 years). Patients with obstetric sphincter injury and idiopathic FI had more permanent stimulator implantations than patients with iatrogenic injury (P = 0.012). Male patients had significantly worse test phase outcomes than female patients (P < 0.001). Age did not influence treatment outcome (P = 0.446) CONCLUSION: Subjective final success of SNS treatment for FI was achieved in 59.3% of patients at a mean of 2.4 years. Gender and the aetiology of FI influenced the test phase and final treatment outcome of SNS treatment.

Increased yield pressure in the anal canal during sacral nerve stimulation: a pilot study with the functional lumen imaging probe

BACKGROUND

Sacral nerve stimulation (SNS) is a well-established treatment for fecal incontinence but its mode of action remains obscure. Anal sphincter function is usually evaluated with manometry but resistance to distension may be a more appropriate parameter than luminal pressure. The functional lumen imaging probe allows detailed description of distension properties of the anal canal. Our objective in this study was to characterize the impact of SNS on distension properties of the anal canal in patients with idiopathic fecal incontinence.

METHODS

We studied 10 women (median age 64 [44-79] years) with idiopathic fecal incontinence at baseline and during SNS. The luminal geometry of the anal canal was examined with the FLIP at rest and during squeeze and the distensibility of the anal canal was investigated during filling of the bag.

KEY RESULTS

All patients were successfully treated with SNS and the mean Wexner Incontinence Score was reduced from 14.9 ± 4 to 7.1 ± 4.8 (P<.001). The pressure required to open the narrowest point of the anal canal during distension (yield pressure) increased from 14.5 ± 12.2 mmHg at baseline to 20.5 ± 13.3 mmHg during SNS (P<.01). The pressure-strain elastic modulus increased non-significantly from 2.2 ± 0.5 to 2.9 ± 1.6 kPa, indicating increased stiffness of the anal canal.

CONCLUSION AND INFERENCES

The yield pressure and the resistance to distension increased in response to SNS for idiopathic fecal incontinence. This will inevitably increase the resistance to flow through the anal canal, which may contribute to the benefits of sacral nerve stimulation.

Evaluation of Trends in the Use of InterStim for Fecal Incontinence

BACKGROUND

Fecal incontinence (FI) represents a large source of morbidity and is a challenging clinical problem to manage. InterStim was approved to treat FI in 2011. Little is known about its adoption. We sought to characterize patterns of use of Interstim since Food and Drug Administration approval for FI.

METHODS

The New York State SPARCS database was used to evaluate InterStim use for FI from 2011 to 2014. The primary endpoint was the number of successful implantations of InterStim. Secondary endpoints included device removal, median time to removal of device, 90-day infection rates, and percentage of procedures performed by surgeon specialty and geographic location.

RESULTS

A total of 369 patients with FI underwent "Stage 1" of InterStim from 2011 to 2014. A total of 302 patients underwent "Stage 2," yielding a trial period failure rate of 18.2%. The majority of patients who underwent successful implantation were female (87.7%) and White (78.8%). Twenty-nine patients underwent device removal after a median duration of 147 days. Estimated risk of removal at median follow-up of 2 years was 11.8%. Colorectal surgeons comprised 51.1% of all providers followed by gynecologic (24.4%) and urologic surgeons (17.8%). A total of 71.7% of providers performed <5 procedures, while 3 of the highest volume providers performed 50.7% of all procedures.

CONCLUSIONS

InterStim for FI has been used by a wide variety of providers in New York State although only a few high-volume providers have performed the majority of procedures. White, female patients with Medicare are the most common recipients of InterStim. Further work must be done to develop strategies for improving access to this technology and to determine whether volume relates to outcomes.

Fecal incontinence - Challenges and solutions

Fecal incontinence is not a diagnosis but a frequent and debilitating common final pathway symptom resulting from numerous different causes. Incontinence not only impacts the patient’s self-esteem and quality of life but may result in significant secondary morbidity, disability, and cost. Treatment is difficult without any panacea and an individualized approach should be chosen that frequently combines different modalities. Several new technologies have been developed and their specific roles will have to be defined. The scope of this review is outline the evaluation and treatment of patients with fecal incontinence.

Evidence-Based Update on Treatments of Fecal Incontinence in Women

Fecal incontinence is a highly prevalent and distressing condition that has a negative impact on quality of life. The etiology is often multifactorial, and the evaluation and treatment of this condition can be hindered by a lack of understanding of the mechanisms and currently available treatment options. This article reviews the evidence-based update for the management of fecal incontinence.

Dynamic Article: Percutaneous Nerve Evaluation Versus Staged Sacral Nerve Stimulation for Fecal Incontinence

BACKGROUND

Sacral neuromodulation using a 2-staged approach is an established therapy for fecal incontinence. Office-based percutaneous nerve evaluation is a less-invasive alternative to the stage 1 procedure but is seldom used in the evaluation of patients with fecal incontinence.

OBJECTIVE

The aim of this study was to determine the clinical success of percutaneous nerve evaluation versus a staged approach.

DESIGN

This was a retrospective review of a prospectively maintained, single-institution database of patients treated with sacral neuromodulation for fecal incontinence.

SETTINGS

This study was conducted at a single academic medical center.

PATIENTS

Eighty-six consecutive patients were treated with sacral neuromodulation for fecal incontinence.

INTERVENTIONS

Percutaneous nerve evaluation was compared with a staged approach.

MAIN OUTCOME MEASURES

The primary outcome measured was the proportion of patients progressing to complete implantation based on >50% improvement in Wexner score during the testing phase.

RESULTS

Percutaneous nerve evaluation was performed in 45 patients, whereas 41 underwent a staged approach. The mean baseline Wexner score did not differ between testing groups. Success was similar between the staged approach and percutaneous nerve evaluation (90.2% versus 82.2%; p = 0.36). The mean 3-month Wexner score was not significantly different between testing methods (4.4 versus 4.1; p = 0.74). However, infection was more likely to occur after the staged approach (10.5% versus 0.0%; p < 0.05).

LIMITATIONS

This study was limited by its retrospective nature and potential for selection bias.

CONCLUSIONS

Percutaneous nerve evaluation offers a viable alternative to a staged approach in the evaluation of patients for sacral neuromodulation in the setting of fecal incontinence. Not only are success rates similar, but percutaneous nerve evaluation also has the benefit of limiting patients to 1 operating room visit and has lower rates of infection as compared with the traditional staged approach for sacral neuromodulation.

Sacral nerve stimulation for faecal incontinence: medium-term follow-up from a single institution

BACKGROUND

Most studies on sacral nerve stimulation (SNS) are either single-centre with small numbers of patients or multi-centre studies. We present the medium-term follow-up results from a single centre for 127 patients undergoing SNS.

METHODS

Consecutive patients treated with SNS for faecal incontinence had preoperative baseline St Mark's continence scores, faecal incontinence quality of life (FIQL) measures and anorectal physiology studies. Follow-up was a postal questionnaire concerning continence, FIQL, patient-perceived change in bowel control (-5 to +5 where 0 is no change), overall satisfaction (0-10 visual analogue scale) and use of medications.

RESULTS

A total of 166 patients underwent temporary nerve stimulation testing, of which 112 progressed to a permanent implantable pulse generator (IPG). Fifteen received an IPG without the testing phase, hence 127 patients in total. Fourteen had the IPG removed, four were deceased, leaving 109 for assessment; 91 (83%) responded to the survey. Mean follow-up was 2.7 years (range: 2 months-8.5 years). Mean baseline St Mark's continence score was 14.4, and mean follow-up score was 10.3 (P < 0.01). FIQL improved in all domains (P < 0.001). Patient-reported improved bowel control mean score was +3.2 (95% CI: 2.9, 3.55). Median satisfaction score was 8.0 (range: 0-10). Complications included 17 lead dislodgements, seven superficial infections, five infections requiring surgery and five repositioning of a rotated IPG. Thirty-two patients used loperamide and 34 used fibre supplements.

CONCLUSION

In this observational study, limited by the absence of a placebo control group, SNS significantly improved continence and quality of life, and patient satisfaction was high.

Systematic Review of Surgical Treatments for Fecal Incontinence

BACKGROUND

No systematic review has examined the collective randomized and nonrandomized evidence for fecal incontinence treatment effectiveness across the range of surgical treatments.

OBJECTIVE

The purpose of this study was to assess the efficacy, comparative effectiveness, and harms of surgical treatments for fecal incontinence in adults.

DATA SOURCES

Ovid MEDLINE, EMBASE, Physiotherapy Evidence Database, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine, and the Cochrane Central Register of Controlled Trials, as well as hand searches of systematic reviews, were used as data sources.

STUDY SELECTION

Two investigators screened abstracts for eligibility (surgical treatment of fecal incontinence in adults, published 1980-2015, randomized controlled trial or observational study with comparator; case series were included for adverse effects). Full-text articles were reviewed for patient-reported outcomes. We extracted data, assessed study risk of bias, and evaluated strength of evidence for each treatment-outcome combination.

INTERVENTIONS

Surgical treatments for fecal incontinence were included interventions.

MAIN OUTCOME MEASURES

Fecal incontinence episodes/severity, quality of life, urgency, and pain were measured.

RESULTS

Twenty-two studies met inclusion criteria (13 randomized trials and 9 observational trials); 53 case series were included for harms. Most patients were middle-aged women with mixed FI etiologies. Intervention and outcome heterogeneity precluded meta-analysis. Evidence was insufficient for all of the surgical comparisons. Few studies examined the same comparisons; no studies were high quality. Functional improvements varied; some authors excluded those patients with complications or lost to follow-up from analyses. Complications ranged from minor to major (infection, bowel obstruction, perforation, and fistula) and were most frequent after the artificial bowel sphincter (22%-100%). Major surgical complications often required reoperation; few required permanent colostomy.

LIMITATIONS

Most evidence is intermediate term, with small patient samples and substantial methodologic limitations.

CONCLUSIONS

Evidence was insufficient to support clinical or policy decisions for any surgical treatments for fecal incontinence in adults. More invasive surgical procedures had substantial complications. The lack of compliance with study reporting standards is a modifiable impediment in the field. Future studies should focus on longer-term outcomes and attempt to identify subgroups of adults who might benefit from specific procedures.

Sacral nerve stimulation--hidden costs (uncovered)

AIM

The aim of this study is to determine the occurrence of surgical revision in a cohort of patients treated with sacral nerve stimulation (SNS) for faecal incontinence and constipation and to establish the types of procedures performed and indications for surgery.

METHOD

From the years 2002 to 2014, 125 patients were identified who had undergone permanent SNS therapy with 36 (28.8 %) patients requiring surgical intervention postimplantation. These cases were retrospectively reviewed (range of follow-up 1-99 months).

RESULTS

Over a total of 1512 months of SNS treatment, 51 unplanned surgical procedures were required in 36 patients. At present, 48 procedures have been performed at an average of 2.6 years following implantation and three patients are awaiting surgery. Lead-related problems accounted for 30 (58.8 %) procedures at an average of 1.7 years affecting 22 patients. Battery and implantable pulse generator-related problems attributed to 13 procedures (25.5 %) in 12 patients at an average of 5.0 years. Battery depletion occurred in seven patients at an average of 5.4 years. Surgical revision was required to replace, remove, or resite various components of the SNS system. Indications for surgery included lead damage, pain and loss or lack of SNS efficacy. Explantation was warranted in six patients due to poor SNS efficacy, pain, infection and facilitation of a magnetic resonance imaging scan. This was performed at an average of 1.6 years.

CONCLUSION

A considerable proportion of patients treated with SNS therapy require surgical revision. These unplanned procedures are associated with substantial unexpected costs that financially burden SNS services.

Sacral nerve stimulation for faecal incontinence - efficacy confirmed from a two-centre prospectively maintained database

INTRODUCTION

Sacral nerve stimulation (SNS) has been recognised as an effective treatment for faecal incontinence. Many unresolved questions could be answered when comparing large data-series from different centres providing prospective data.

AIM

To present data, from an international two-centre SNS prospective database (SNSPD) on functional outcome and management of surgical complications in patients treated with SNS for faecal incontinence.

METHOD

The SNSPD was designed in order to gather detailed pre- and perioperative information followed by a close follow-up in all patients undergoing SNS for bowel dysfunction. The SNSPD was open for inclusion of newly SNS implanted patients in May 2009, and closed on 31 December 2013. Two-centres Aarhus, Denmark, and Nantes, France, included and monitored all patients implanted due to bowel dysfunction according to database criteria.

RESULTS

In total, 164 faecal incontinent patients with a median follow-up of 22 (range 1-50) months were implanted. The Wexner incontinence score improved from 15 (range, 3-20) at baseline to 9 (range, 0-20) at latest follow-up (P < 0.001) and VAS impact on daily life improved from 85.5 (range, 3-100) to 20 (range, 0-100) (P < 0.001). Additional surgical intervention was required in 19.5 % during follow-up. Repositioning of the pacemaker due to pain or migration was the most common complication in 12.1 %. Infections leading to explantation occurred in 3.0 %.

Management of patients with faecal incontinence

Faecal incontinence, defined as the involuntary loss of solid or liquid stool, is a common problem affecting 0.8-8.3% of the adult population. Individuals suffering from faecal incontinence often live a restricted life with reduced quality of life. The present paper is a clinically oriented review of the pathophysiology, evaluation and treatment of faecal incontinence. First-line therapy should be conservative and usually include dietary adjustments, fibre supplement, constipating agents or mini enemas. Biofeedback therapy to improve external anal sphincter function can be offered but the evidence for long-term effect is poor. There is good evidence that colonic irrigation can reduce symptoms and improve quality of life, especially in patients with neurogenic faecal incontinence. Surgical interventions should only be considered if conservative measures fail. Sacral nerve stimulation is a minimally invasive procedure with high rate of success. Advanced surgical procedures should be restricted to highly selected patients and only performed at specialist centres. A stoma should be considered if other treatment modalities fail.

Bilateral compared with unilateral sacral nerve stimulation for faecal incontinence: results of a randomized, single-blinded crossover study

AIM

This randomized single-blinded crossover study aimed to investigate whether bilateral sacral nerve stimulation (SNS) is more efficient than unilateral stimulation for faecal incontinence (FI).

METHOD

Patients with FI who responded during a unilateral test stimulation, with a minimum improvement of 50% were eligible. Twenty-seven patients who were accepted to enter the trial were bilaterally implanted with two permanent leads and pacemakers. Patients were randomized into three periods of 4 weeks' stimulation including unilateral right, unilateral left and bilateral stimulation. Symptoms scores and bowel habit diaries were collected at baseline and in each study period. A 1-week washout was introduced between each study period.

RESULTS

Twenty-seven (25 female) patients with a median age of 63 (36-84) years were bilaterally implanted from May 2009 to June 2012. The median number of episodes of FI per 3 weeks significantly decreased from 17 (3-54) at baseline to 2 (0-20) during stimulation on the right side, 2 (0-42) during stimulation on the left side and 1 (0-25) during bilateral stimulation. The Wexner incontinence score improved significantly from a median of 16 (10-20) at baseline to 9 (0-14) with right-side stimulation, 10 (0-15) with left-side stimulation and 9 (0-14) with bilateral stimulation. The differences between unilateral right or unilateral left and bilateral stimulation were non-significant, for FI episodes (P = 0.3) or for Wexner incontinence score (P = 0.9).

CONCLUSION

Bilateral SNS therapy for FI is not superior to standard unilateral stimulation in the short term. Equal functional results can be obtained regardless of the side of implantation.

Transcutaneous Electrical Nerve Stimulation Increases Rectal Activity in Children

OBJECTIVES

Neurostimulation is increasingly used in treating bladder and bowel dysfunction, but its effect on rectal motility is obscure. The aim of the study was to evaluate the acute effect of transcutaneous electrical nerve stimulation (TENS) on rectal motility in children with overactive bladder (OAB).

METHODS

In this double-blind placebo-controlled study in 20 children with OAB (mean age 8.6 ± 1.8 years; 7 girls), 48-hour urodynamic monitoring including rectal manometry was performed. After 24-hours of baseline investigation without stimulation the children were randomised to either active TENS (n = 10) or placebo (n = 10). Surface electrodes were placed over the sacral bone. The exterior of active and placebo stimulators was identical. Starting in the morning, the children received either continuous TENS stimulation or placebo until bedtime. Rectal contractions were de&filig;ned as pressure runs exceeding 5 cm H2O and lasting ≥3 minutes.

RESULTS

At baseline there was no significant difference in proportion of time with rectal contractions in the 2 groups (TENS group median 31% [range 12%-66%] vs placebo group median 31% [range 10%-66%]; P = 0.75); however, on the day of stimulation there was more time with rectal contractions in the group receiving TENS (median 51% [range 25%-78%]) compared with placebo (median 32% [range 4%-68%]; P = 0.02). Also, there was an increase in time with rectal contractions in the TENS group (P = 0.007) but not in the placebo group (P = 0.39). The night after the TENS was disabled, rectal activity in both groups returned to baseline level.

CONCLUSIONS

TENS acutely increases time with rectal contractions in children undergoing urodynamic investigation. The effect disappears when the stimulator is turned off.

Abnormal neuronal response to rectal and anal stimuli in patients with idiopathic fecal incontinence

BACKGROUND

The pathophysiology behind idiopathic fecal incontinence (IFI) is poorly understood. We hypothesized abnormal sensory pathways along the brain-gut axis as a key player in this disease, reflected in cortical evoked potentials (CEP) from mechanical stimuli of the rectum and the anal canal.

METHODS

CEPs were recorded during repeated rapid balloon distensions of the rectum and anal canal in 19 women with IFI (mean age: 60 ± 14, mean Wexner score: 14.7 ± 2.9) and in 19 healthy women (mean age: 56 ± 11, mean Wexner score: 1.1 ± 1.3). Latencies, amplitudes and topography of CEPs elicited by rectal distension were compared between the groups. CEPs from both rectal and anal distensions were examined using spectral band analysis of single sweeps determining the relative amplitude of five spectral bands as a proxy of neuronal processing.

KEY RESULTS

Compared to controls IFI patients had prolonged latency of CEPs from rectal distension by up to 27% (p < 0.001) while amplitudes and topography were similar (all p > 0.7 and all p > 0.23). Spectral analysis of CEPs from rectal distensions showed no difference (all p > 0.1) between groups. However, analysis of CEPs following distension of the anal canal resulted in abnormally low activity in beta (8-12 Hz; p < 0.001) band and high activity in the gamma (32-70 Hz; p = 0.04) band in patients.

CONCLUSIONS & INFERENCES

IFI seems to be associated with impaired ano-rectal sensory functions in both the afferent fibers to the brain and the cortical processing of anal sensory pathways. This may play a central role for the pathogenesis of IFI.

Does preoperative anal physiology testing or ultrasonography predict clinical outcome with sacral neuromodulation for fecal incontinence?

INTRODUCTION AND HYPOTHESIS

To determine the value of preoperative anal physiology testing and transanal ultrasonography in predicting clinical response to sacral neuromodulation for fecal incontinence.

METHODS

We report a retrospective study of all patients treated with sacral neuromodulation for fecal incontinence in a single practice between 2011 and 2014 was performed. Patient demographics included age, gender, comorbidities, presence of an ultrasound-defined external sphincter defect, and history of prior anal sphincter repair. Cleveland Clinic Florida (CCF) scores were used to assess the severity of fecal incontinence at baseline, and at 3, 6 and 12 months. Pearson's correlation coefficient was used to evaluate the relationship between preoperative physiology testing and ultrasonography and patient outcome.

RESULTS

Sacral neuromodulation was trialed in 60 patients, of whom 31 had anorectal physiology testing and 29 did not. Patients who were tested were younger (60.9 vs. 71.4 years, p = 0.013) and more likely to have had a prior overlapping sphincteroplasty (40.5% vs. 15%, p = 0.043). Among patients who progressed to complete system implantation, CCF scores at 3 and 12 months were similar whether they had physiology testing or not. Likewise, patient outcome did not correlate with the finding of an ultrasound-defined external sphincter defect. Pearson's correlation coefficient was used to evaluate the relationship between the test results and the 3-month CCF scores. CCF scores 3 months after full system implantation did not correlate with the presence or size of an external sphincter defect, resting or squeeze pressure, pudendal nerve terminal motor latency, rectoanal inhibitory reflex, or minimum detectable volume.

CONCLUSIONS

Anal physiology testing and ultrasonography were not predictive of clinical outcomes among patients treated with sacral neuromodulation for fecal incontinence.

Sacral nerve stimulation for faecal incontinence and constipation: a European consensus statement

AIM

In Europe during the last decade sacral nerve stimulation (SNS) or sacral neuromodulation (SNM) has been used to treat faecal incontinence (FI) and constipation. Despite this, there is little consensus on baseline investigations, patient selection and operative technique. A modified Delphi process was conducted to seek consensus on the current practice of SNS/SNM for FI and constipation.

METHOD

A systematic literature search of SNS for FI and constipation was conducted using PubMed. A set of questions derived from the search and expert opinion were answered on-line on two occasions by an international panel of specialists from Europe. A 1-day face-to-face meeting of the experts finalized the discussion.

RESULTS

Three hundred and ninety-three articles were identified from the literature search, of which 147 fulfilled the inclusion criteria. Twenty-two specialists in FI and constipation from Europe participated. Agreement was achieved on 43 (86%) of 50 domains including the set-up of service, patient selection, baseline investigations, operative technique and programming of the device. The median of agreement was 95% (35-100%).

CONCLUSION

Consensus was achieved on the majority of domains of SNS/SNM for FI and constipation. This should serve as a benchmark for safe and quality practice of SNS/SNM in Europe.

Is sacral neuromodulation here to stay? Clinical outcomes of a new treatment for fecal incontinence

INTRODUCTION

Sacral neuromodulation (SNM) was approved by the FDA for the treatment of fecal incontinence (FI) in 2011, and previous industry-sponsored trials have shown excellent clinical outcomes. The purpose of this study is to examine clinical outcomes of patients treated during our initial experience with SNM.

METHODS

A prospective database of patients treated with SNM for FI by one of three colorectal surgeons at two separate institutions was maintained starting in 2011. Patients showing ≥50% improvement of weekly incontinent episodes during test stimulation were offered permanent implantation of the SNM device. Disease severity was tracked using the Wexner score.

RESULTS

A total of 145 patients received a full system implantation (of 152 who received test stimulation). The median preoperative Wexner score of 14 decreased to 3, 3 months after implantation and persisted to 12 months. At 12 months, 95.2% of patients achieved >50% improvement in Wexner Score and 67.6% achieved >75% improvement. The most common adverse event was infection (3.4%). Three patients (2.1%) required lead revision.

CONCLUSIONS

SNM is a safe and effective therapy for the treatment of FI. Postoperative patient surveillance is important, as many patients require programming changes, and some will require a lead revision over time.

Gastrointestinal Symptoms in Parkinson Disease: Clinical Aspects and Management

Although it is now generally recognized that the clinical spectrum of Parkinson disease (PD) is broader than its defining motor aspects, its various non-motor symptoms are often not routinely assessed in the clinical setting. As most of these symptoms are amenable to treatment, improved recognition would lead to more comprehensive management of the disease, and ultimately improve the quality of life for PD patients. In an attempt to increase the general awareness of physicians caring for these patients, this article focuses on the clinical manifestations and treatment of the gastrointestinal symptoms most commonly experienced by PD patients, as well as on the gastrointestinal side effects of antiparkinsonian treatments.

A systematic review of sacral nerve stimulation mechanisms in the treatment of fecal incontinence and constipation

BACKGROUND

Sacral nerve stimulation (SNS) is now well established as a treatment for fecal incontinence (FI) resistant to conservative measures and may also have utility in the management of chronic constipation; however, mechanism of action is not fully understood. End organ effects of SNS have been studied in both clinical and experimental settings, but interpretation is difficult due to the multitude of techniques used and heterogeneity of reported findings. The aim of this study was to systematically review available evidence on the mechanisms of SNS in the treatment of FI and constipation.

METHODS

Two systematic reviews of the literature (performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses framework) were performed to identify manuscripts pertaining to (a) clinical and (b) physiological effects of SNS during the management of hindgut dysfunction.

KEY RESULTS

The clinical literature search revealed 161 articles, of which 53 were deemed suitable for analysis. The experimental literature search revealed 43 articles, of which nine were deemed suitable for analysis. These studies reported results of investigative techniques examining changes in cortical, gastrointestinal, colonic, rectal, and anal function.

CONCLUSIONS & INFERENCES

The initial hypothesis that the mechanism of SNS was primarily peripheral motor neurostimulation is not supported by the majority of recent studies. Due to the large body of evidence demonstrating effects outside of the anorectum, it appears likely that the influence of SNS on anorectal function occurs at a pelvic afferent or central level.

Baseline factors predictive of patient satisfaction with sacral neuromodulation for idiopathic fecal incontinence

PURPOSE

Sacral neuromodulation (SNM) is an established treatment for fecal incontinence (FI). A recent study from our group found that the relationship between patient satisfaction and clinical outcome is complex and does not match the traditional used success criteria. Therefore, the ability to predict patient satisfaction must be given priority. The aim of the present study is to identify baseline factors predictive of patient satisfaction, with SNM, for idiopathic FI.

METHODS

We analyzed data from patients treated with SNM for idiopathic FI in Aarhus, Denmark, and Maastricht, The Netherlands. A questionnaire considering self-reported satisfaction was mailed to these patients and compared to baseline characteristics. Logistic regression was used to determine the predictive value of baseline demographic and diagnostic variables.

RESULTS

In total, 131 patients were included in the analysis. Patient satisfaction with the current treatment result was reported in 75 patients. Fifty-six patients were dissatisfied with SNM treatment, after median 46 months (range 11-122) with permanent implantation. Pudendal nerve terminal motor latency (PNTML) was the solely identified predictor for long-term patient satisfaction. A subgroup univariate-logistic regression analysis showed that PNTML ≤ 2.3 ms at the side of lead implantation was a statistically significant predictor for patient satisfaction (odds ratio (OR) 2.3, 95% confidence interval (CI) 1.01-5.24, p = 0.048).

CONCLUSION

Baseline PNTML measurement may be predictive of long-term satisfaction with SNM therapy for idiopathic FI. Further studies are needed to confirm this result.

Sacral neuromodulation and peripheral nerve stimulation in patients with anal incontinence: an overview of techniques, complications and troubleshooting

Sacral neuromodulation (SNM) therapy has revolutionized the management of many forms of anal incontinence, with an expanded use and a medium-term efficacy of 75% overall. This review discusses the technique of SNM therapy, along with its complications and troubleshooting and a discussion of the early data pertaining to peripheral posterior tibial nerve stimulation in incontinent patients. Future work needs to define the predictive factors for neurostimulatory success, along with the likely mechanisms of action of their therapeutic action.

Current status: new technologies for the treatment of patients with fecal incontinence

Fecal incontinence is a frequent and debilitating condition that may result from a multitude of different causes. Treatment is often challenging and needs to be individualized. During the last several years, new technologies have been developed, and others are emerging from clinical trials to commercialization. Although their specific roles in the management of fecal incontinence have not yet been completely defined, surgeons have access to them and patients may request them. The purpose of this project is to put into perspective, for both the patient and the practitioner, the relative positions of new and emerging technologies in order to propose a treatment algorithm.

Sacral nerve stimulation for the treatment of severe faecal incontinence: results after 10 years experience

INTRODUCTION

The objective of this study is to report our experience with sacral nerve stimulation for the treatment of severe faecal incontinence after the first 10 years with this technique.

MATERIAL AND METHODS

Between 2001 and 2011, 49 patients with severe faecal incontinence underwent sacral nerve stimulation. Anorectal manometry, endoanal ultrasound and pudendal nerve latency were performed. Bowel habit diary, severity of faecal incontinence and quality of life scales were evaluated preoperatively and at the end of follow-up.

RESULTS

Morbidity occurred in a third of patients, mostly minor. Four definitive devices were explanted. With a median follow-up of 37 months, severity of faecal incontinence, urge and incontinence episodes significantly improved at the end of follow-up. Patients' subgroup with major follow-up of 5 years significantly improved the severity of faecal incontinence but not the parameters of the bowel habit diary. Quality of life showed no significant improvement. Descriptive data in patients with sphincter defects did not show worse results than with sphincter integrity.

CONCLUSION

Sacral nerve stimulation is a safe technique for severe faecal incontinence with good functional medium-term results. In the long term, severity of the faecal incontinence also improves but studies with larger sample are necessary to show if other clinical parameters and the quality of life support this information. Preliminary results in patients with sphincter defects suggest that this technique could be effective in this group but future studies will have to confirm these findings.

Systematic review of the clinical effectiveness of neuromodulation in the treatment of faecal incontinence

BACKGROUND

Over the past 18 years neuromodulation therapies have gained support as treatments for faecal incontinence (FI); sacral nerve stimulation (SNS) is the most established of these. A systematic review was performed of current evidence regarding the clinical effectiveness of neuromodulation treatments for FI.

METHODS

The review adhered to the PRISMA framework. A comprehensive search of the literature included PubMed, MEDLINE, Embase and Evidence-Based Medicine Reviews. Methodological quality assessment and data extraction were completed in a systematic fashion.

RESULTS

For SNS, 321 citations were identified initially, of which 61 studies were eligible for inclusion. Of studies on other neuromodulation techniques, 11 were eligible for review: seven on percutaneous tibial nerve stimulation (PTNS) and four on transcutaneous tibial nerve stimulation (TTNS). On intention-to-treat, the median (range) success rates for SNS were 63 (33-66), 58 (52-81) and 54 (50-58) per cent in the short, medium and long terms respectively. The success rate for PTNS was 59 per cent at the longest reported follow-up of 12 months. SNS, PTNS and TTNS techniques also resulted in improvements in Cleveland Clinic Incontinence Score and quality-of-life measures. Despite significant use of neuromodulation in treatment of FI, there is still no consensus on outcome reporting in terms of measures used, aetiologies assessed, length of follow-up or assessment standards.

CONCLUSION

Emerging data for SNS suggest maintenance of its initial therapeutic effect into the long term. The clinical effectiveness of PTNS is comparable to that of SNS at 12 months, although there is no evidence to support its continued effectiveness after this period. PTNS may be a useful treatment before SNS. The clinical effectiveness of TTNS is still uncertain owing to the paucity of available evidence. A consensus to standardize the use of outcome measures is recommended in order that further reports can be compared meaningfully.

Neuromodulation for fecal incontinence: An effective surgical intervention

Fecal incontinence is a disabling symptom with medical and social implications, including fear, embarrassment, isolation and even depression. Most patients live in seclusion and have to plan their life around the symptom, with secondary impairment of their quality of life. Conservative management and biofeedback therapy are reported to benefit a good percentage of those affected. However, surgery must be considered in the non-responder population. Recently, sacral nerve electrostimulation, lately named neuromodulation, has been reported to benefit patients with fecal incontinence in randomized controlled trials more than placebo stimulation and conservative management, by some unknown mechanism. Neuromodulation is a minimally invasive procedure with a low rate of adverse events and apparently favorable cost-efficacy profile. This review is intended to expand knowledge about this effective intervention among the non-surgically skilled community who deals with this disabled group of patients.

Efficacy of cyclic sacral nerve stimulation for faecal incontinence

BACKGROUND

Sacral nerve stimulation (SNS) is an established treatment option for faecal incontinence. Cyclic stimulation will improve the longevity of the implanted stimulator, but little is known about its efficacy. The aim of this retrospective clinical study was to assess the efficacy of cyclic SNS for faecal incontinence.

METHODS

Sixty-three patients underwent percutaneous nerve evaluation (PNE) test with a 2-week period of continuous SNS. The PNE test was deemed positive in 42 patients (67 %) who underwent implantation with permanent stimulator. All 42 patients were initially stimulated in a cyclic manner with stimulation for 20 s followed by 8 s without. During follow-up, the stimulator was explanted in 2 patients and permanently turned off in one due to the loss of effect. A postal questionnaire including the Wexner score, a general quality of life (Qol) score, and a bowel habit diary was distributed to 39 patients.

RESULTS

The questionnaire was returned by 29/39 (74 %) of the patients. Median duration of follow-up was 16 (range 3-34) months. The Wexner score and the general QoL score were significantly improved compared to pre-treatment values. Some 18 patients (62 %) were still treated with cyclic stimulation at follow-up, reporting more frequent episodes of urgency without incontinence (p = 0.020) compared to symptoms during the PNE test. Patients who had changed to continuous stimulation due to a suboptimal effect during follow-up reported more frequent episodes of urgency with incontinence (p = 0.034), minor soiling (p = 0.045) and days wearing pads (p = 0.027) compared with symptoms during the PNE test.

CONCLUSIONS

Cyclic stimulation seems effective for most patients treated with SNS for faecal incontinence.

Sacral nerve stimulation at subsensory threshold does not compromise treatment efficacy: results from a randomized, blinded crossover study

BACKGROUND AND OBJECTIVE

: Stimulation amplitude used in sacral nerve stimulation (SNS) is at or just above the sensory threshold (ST). This randomized, blinded crossover study aimed to document if stimulation at 75% or 50% of the ST would be as effective as stimulation at the ST for fecal incontinence (FI).

METHOD

: FI patients treated with SNS, who were satisfied with current treatment results and had a minimum symptom reduction of 75%, were eligible. Patients were randomized into 3 periods of 4-week stimulation: ST, 75% of the ST, and 50% of the ST. Patients completed a bowel habit diary and questionnaires on bowel functions and patient satisfaction at the study baseline and in each study period.

RESULTS

: Nineteen patients (18 females) with a mean follow-up of 51.7 ± 29.9 months were included from January to April 2010. The mean FI episodes per 3 weeks decreased from pre-SNS therapy 33.6 ± 31.6 to 1.1 ± 2.2 at the study baseline (P < 0.001). Decreasing the stimulation amplitude to as low as 50% of the ST did not affect the overall number of incontinent episodes (P = 0.078). The Wexner incontinence score dropped from 16.5 ± 2.5 for pre-SNS therapy to 7.4 ± 3.1 at the study baseline (P < 0.001). Decreasing the stimulation amplitude to ST, 75% of the ST or 50% of the ST, did not change the Wexner score when compared with the study baseline (P = 0.581). In general, patient satisfaction was high at the study baseline and did not deteriorate as the stimulation amplitude was decreased to 50% of the ST (P = 0.932).

CONCLUSIONS

: Subsensory stimulation as low as 50% of the ST is as effective as stimulation at or above the ST. The study was approved by the Regional Committee on Biomedical Research Ethics, Denmark, and registered at ClinicalTrials.gov (NCT01130870).

Sacral nerve stimulation for fecal incontinence improves symptoms, quality of life and patients' satisfaction: results of a monocentric series of 119 patients

PURPOSE

Sacral nerve stimulation (SNS) is validated as an efficient treatment for fecal incontinence (FI). However, long-term results are scarce in the literature. The goal of this study was to assess the impact of SNS on FI symptoms and quality of life, based on a retrospective analysis of prospectively collected data.

METHODS

From 2001 to 2009, 119 patients (six men, mean age 61 years) underwent SNS testing for FI after an extensive diagnostic workup. Permanent implantation was realized when FI symptoms improved during testing, and follow-up visits were performed every 12 months thereafter. This follow-up evaluated morbidity and efficacy, based on clinical data and self-administered questionnaires including Jorge and Wexner FI score, urinary incontinence score (urinary distress inventory-6, UDI-6), gastrointestinal quality of life index (GIQLI), and auto-evaluation scale.

RESULTS

A permanent stimulator was implanted after a positive test in 102 patients (91 %). Ten patients were explanted during follow-up (pain in one case and absence of efficacy in nine), and 29 had the stimulator and/or the electrode changed. The mean follow-up was 48 months (range 12-84): there was a significant improvement of FI score (9 ± 1 vs 14 ± 3, p < 0.0001), UDI-6 score (8 ± 4 vs 11 ± 5, p < 0.05), and GIQLI index (p < 0.002). The improvement was present at 12 months follow-up and remained stable. Eighty percent of patients were satisfied with the treatment at the last point of follow-up. None of the pretreatment variables were predictive of SNS efficacy.

CONCLUSIONS

SNS improved FI and quality of life, and this efficacy remained over time. Although a complete disappearance of FI was rare, most patients were satisfied.

Cost-effectiveness analysis of sacral neuromodulation for faecal incontinence in The Netherlands

AIM

Sacral neuromodulation (SNM) plays a major part in the algorithm of management of faecal incontinence, but there are limited data on its cost-effectiveness. This study aimed to analyse this and the quality-adjusted life-years (QALYs) associated with two different treatment algorithms. The first (SNM-) included use of an artificial sphincter [dynamic graciloplasty (DGP) (50%) and artificial bowel sphincter (ABS) (50%)]. The second (SNM+) included SNM (80% of cases) and artificial sphincter (DGP 10%; ABS 10%) The incidence of sphincteroplasty was assumed to be equal in both algorithms.

METHOD

A Markov model was developed. A hypothetical cohort of patients was run through both strategies of the model. A mailed EuroQoL-5D questionnaire was used to determine health-related quality of life. Costs were reproduced from the Maastricht University Medical Centre prospective faecal incontinence database. The time scale of the analysis was 5 years.

RESULTS

The former treatment protocol cost €22,651 per patient and the latter, after the introduction of SNM, cost €16,473 per patient. The former treatment protocol resulted in a success rate of 0.59 after 5 years, whereas with the introduction of SNM this was 0.82. Adhering to the former treatment protocol yielded 4.14 QALYs and implementing the latter produced 4.21 QALYs.

CONCLUSION

The study demonstrated that introducing SNM in the surgical management algorithm for faecal incontinence was both more effective and less costly than DGP or ABS without SNM. This justifies adequate funding for SNM for patients with faecal incontinence.

Sacral nerve stimulation in the treatment of fecal incontinence - the experience of a pelvic floor center : short term results

OBJECTIVES

The aim of this paper is to present the data pertinent to the experiences of our Pelvic Floor Center on the utilisation of SNS in the treatment of fecal incontinence and compare these data to the data of current literature.

METHODS

All patients who had had SNS treatment for fecal incontinence between the dates of 1st April 2008 and 1st April 2011 were enrolled in the study. We considered a 50% reduction of fecal incontinence episodes as a success of the test phase. The score used for assessment was the Cleveland Clinic Florida-Fecal Incontinence score (CCF-FI).

RESULTS

The 21 patients treated for fecal incontinence (19 ♀ and 2 ♂, average age 59.7 [ 26-73] years) were sub-divided on the basis of the presence or absence of sphincter damage (group A1 had damage while group A2 did not). A patient (group A1) was excluded from the study as the result of the external connector breaking during the test phase. Of the 20 remaining patients (9 from group A1 and 11 from A2), 14 (70%) felt benefit and subsequently underwent definitive stimulator implantation. The variation between the pre-operative CCF-FI and the value at 6 months was statistically significant both in group A1 (p=0.009) and in group A2 (p=0.003). The only complication reported was one case (7.1%) of infection of the definitive stimulator.

CONCLUSION

SNS represents an effective treatment for patients with fecal incontinence. The results have been encouraging, and in line with current literature.

Randomized double-blind crossover study of alternative stimulator settings in sacral nerve stimulation for faecal incontinence

Background

Sacral nerve stimulation is an established treatment for faecal incontinence. Nearly half of all patients experience loss of efficacy at some point. Standard reprogramming restores efficacy for some, but not all, patients. This study aimed to determine whether alternative stimulator settings would increase treatment efficacy.

Methods

Patients with sustained loss of efficacy were recruited from two international specialist centres. A number of alternative stimulation parameters were tested using a double-blind randomized crossover study design. Stimulation settings tested were pulse frequencies of 6·9 and 31 Hz, and pulse widths of 90 and 330 µs, compared with one standard setting of 14 Hz/210 µs. Treatment efficacy was evaluated using a disease-specific quality-of-life score (Fecal Incontinence Quality of Life Scale, FIQLS) and a bowel habit diary completed before randomization, during the study period and after 3 months of follow-up with one preferred setting.

Results

Fifteen patients were analysed. With one preferred setting, three of four subdomains in the FIQLS improved significantly. The mean(s.d.) total number of incontinence episodes dropped from 11·7(10·8) to 4·8(4·5) per 3 weeks (P = 0·011) and improvements were maintained after 3 months of follow-up. Optimal pacemaker settings were individual, but a trend towards highest patient satisfaction and improved treatment outcome was evident for high-frequency stimulation (31 Hz/210 µs), which was preferred by eight of the 15 patients.

Conclusion

Patients experiencing loss of efficacy can experience improvement if alternative pacemaker settings are tested. High-frequency stimulation (31 Hz/210 µs) was preferred by more than half of the patients, and improved treatment outcome was sustained at 3 months. Registration number: NCT01254695 (http://www.clinicaltrials.gov).

The management of gastrointestinal symptoms in Parkinson's disease

The involvement of the autonomic nervous system in Parkinson's disease causes many non-motor symptoms, among which gastrointestinal complaints are prominent. Drooling, dyspepsia, constipation, abdominal pain and fecal incontinence are frequently a source of patient distress. Dysphagia is recognized as causing both discomfort and increased risk of serious complications. Although a diagnosis can often be established based on the reports of patients and/or caregivers, and additional testing is seldom required, these diagnoses are clearly under recognized in clinical practice. These symptoms respond to the same treatment measures used in the general population, although certain drugs with a potential to increase parkinsonian symptoms should be avoided. Increased and early identification of these symptoms can result in a significant improvement in the quality of life of Parkinson's disease patients.

Functional results and patient satisfaction with sacral nerve stimulation for idiopathic faecal incontinence

AIM

Sacral nerve stimulation (SNS) is an established treatment for faecal incontinence (FI) when conservative modalities have failed to restore continence. This two-centre study aimed to document functional outcome and its relationship to patient satisfaction.

METHOD

Patients treated with SNS for idiopathic FI in Aarhus (Denmark) and Maastricht (The Netherlands) were included. At the most recent follow-up appointment, 127 patients (80%) were identified as receiving active SNS therapy. A questionnaire considering bowel habits, quality of life, and self-reported satisfaction and a 3-week bowel-habit diary were mailed to these patients, and 85% responded.

RESULTS

Patient satisfaction was clearly related to the number of FI episodes. Patients experiencing full continence were all satisfied, and although the satisfaction rate decreased as the number of FI episodes increased, 46% of the patients with more FI episodes at follow-up than at baseline were still satisfied. Per-protocol analysis resulted in a satisfaction rate of 57.3%. In total, 74.7% of the patients receiving active SNS therapy reported a reduction of ≥ 50% in FI episodes, 10.3% of whom were dissatisfied after a median of 46 months of follow-up.

CONCLUSION

There is a clear relationship between patient satisfaction and improved continence. A total of 57.3% of the patients offered SNS therapy were satisfied at follow-up. However, 46% of the patients with more FI episodes at follow-up than at baseline were also satisfied. Therefore, functional outcome of SNS therapy cannot be based only on bowel-habit diaries and bowel scores.

Electrical stimulation of the dorsal clitoral nerve reduces incontinence episodes in idiopathic faecal incontinent patients: a pilot study

AIM

Faecal incontinence (FI) has a significant impact on quality of life. This study investigates whether stimulation of the dorsal genital nerve (DGN) improves FI symptoms.

METHOD

Ten female patients suffering from idiopathic FI (median age 60 years) were included in the study. Stimulation was applied twice daily for 3 weeks at the maximal tolerable stimulation amplitude (pulse width, 200 μs; pulse rate, 20 Hz). Patients kept a 3-week bowel diary prior to stimulation, during stimulation and after the final stimulation. FI severity scores, FI Severity Visual-Analogue Score (VAS), FI Quality of Life Score (FIQL), sphincter function and rectal volume tolerance were assessed at baseline, immediately after stimulation and 3 weeks after stimulation.

RESULTS

Nine patients completed the study. The Wexner score (P=0.027) and the St Mark's score (P=0.035) improved after stimulation in seven and six of the patients and improvement was maintained 3 weeks after stimulation (P=0.048 and P=0.049, respectively). The number of incontinent episodes was reduced in seven out of nine patients (P=0.025). Improvement was maintained for 3 weeks after stimulation (P=0.017). Subjective assessments of FI severity using the VAS score and the FIQl score did not improve during stimulation. Sphincter function and rectal volume tolerability were unaffected.

CONCLUSION

DGN stimulation reduced the number of FI episodes in most patients suffering from idiopathic FI. Sphincter function and rectal volume tolerability were not affected. DGN stimulation may represent a new treatment for idiopathic FI.