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Martín Prieto L, Pascual Migueláñez I, Fernández Cebrián JM, Martínez Puente MC, Varillas-Delgado D, Fernández Rodríguez M, Pascual Montero JA. Targeted Electromyographic Biofeedback With Endoanal Electrostimulation for Anal Incontinence. Surg Innov 2023; 30:56-63. [PMID: 35509238 DOI: 10.1177/15533506221096885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose. Anal incontinence (AI) is a disabling condition with a variable response to conservative physical therapies. We assess the utility of combining electromyographic biofeedback with endoanal electrostimulation targeted to the weakest areas of the pelvic floor using the MAPLe® probe (Multiple Array Probe Leiden Novuqare). Methods. Patients with AI unresponsive to conservative measures were assessed before and after treatment with anorectal manometry (ARM), electromyography (EMG), Wexner Continence Scoring, Visual Analog Scoring (VAS), FIQL and SF-12 quality of life determination. Results. Of 29 patients in the final analysis, there was an improvement in the mean Wexner continence score from 13.59 to 8.03 and a concomitant improvement in the reported VAS from 3.45 to 6.72. Both Wexner continence and VAS scores were maintained during follow-up. Maximum voluntary manometric contraction significantly improved from 91.76 mmHg to 110.33 mmHg with no changes in resting pressure. The EMG values (μV) that significantly improved included the average and peak resistance, the average general voluntary contraction, and the average and peak voluntary contraction for both the external anal sphincter and the puborectalis. In the FIQL, behavior, depression and shame domains improved after treatment and during follow-up with lifestyle improvements detected at 6 and 12 months. Physical and mental components of the SF-12 improved at 6 and 12 months. Conclusions. Targeted electromyographic biofeedback and endoanal electrostimulation using MAPLe® probe in AI patients sustainably improves objective ARM and EMG parameters along with subjective reporting of continence severity, VAS, and quality of life.
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Affiliation(s)
- L Martín Prieto
- Department Coloproctology and General Surgery, 88129Clinica CEMTRO, Madrid, Spain.,Department General and Digestive Surgery, 221912Hospital El Escorial, San Lorenzo de El Escorial, Spain
| | - I Pascual Migueláñez
- Department Coloproctology and General Surgery, 88129Clinica CEMTRO, Madrid, Spain.,Department General and Digestive Surgery, 16268University Hospital La Paz, Madrid, Spain
| | - J M Fernández Cebrián
- Department Coloproctology and General Surgery, 88129Clinica CEMTRO, Madrid, Spain.,Department General and Digestive Surgery, 16507University Hospital Ramón y Cajal, Madrid, Spain
| | - M C Martínez Puente
- Department Coloproctology and General Surgery, 88129Clinica CEMTRO, Madrid, Spain
| | - D Varillas-Delgado
- Faculty of Health Sciences, Exercise and Sport Sciences, 16447University Francisco de Vitoria, Madrid, Spain
| | - M Fernández Rodríguez
- Department General and Digestive Surgery, 16370University Hospital Puerta Hierro, Madrid, Spain
| | - J A Pascual Montero
- Department Coloproctology and General Surgery, 88129Clinica CEMTRO, Madrid, Spain
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Kropshofer S, Aigmüller T, Beilecke K, Frudinger A, Krögler-Halpern K, Hanzal E, Helmer H, Hölbfer S, Huemer H, Van MK, Kronberger I, Kuhn A, Pfeifer J, Reisenauer C, Tamussino K, Umek W, Kölle D, Abou-Dakn M, Gabriel B, Schwandner O, Pristauz-Telsnigg G, Welskop P, Bader W. Management of Third and Fourth-Degree Perineal Tears After Vaginal Birth. Guideline of the DGGG, OEGGG and SGGG (S2k-Level, AWMF Registry No. 015/079, December
2020). Geburtshilfe Frauenheilkd 2022; 83:165-183. [PMID: 37151735 PMCID: PMC10155200 DOI: 10.1055/a-1933-2647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 08/23/2022] [Indexed: 12/12/2022] Open
Abstract
Abstract
Purpose This guideline provides recommendations for the diagnosis, treatment and follow-up care of 3rd and 4th degree perineal tears which occur during vaginal birth. The aim is to
improve the management of 3rd and 4th degree perineal tears and reduce the immediate and long-term damage. The guideline is intended for midwives, obstetricians and physicians involved in
caring for high-grade perineal tears.
Methods A selective search of the literature was carried out. Consensus about the recommendations and statements was achieved as part of a structured process during a consensus
conference with neutral moderation.
Recommendations After every vaginal birth, a careful inspection and/or palpation by the obstetrician and/or the midwife must be carried out to exclude a 3rd or 4th degree perineal
tear. Vaginal and anorectal palpation is essential to assess the extent of birth trauma. The surgical team must also include a specialist physician with the appropriate expertise (preferably
an obstetrician or a gynecologist or a specialist for coloproctology) who must be on call. In exceptional cases, treatment may also be delayed for up to 12 hours postpartum to ensure that a
specialist is available to treat the individual layers affected by trauma. As neither the end-to-end technique nor the overlapping technique have been found to offer better results for the
management of tears of the external anal sphincter, the surgeon must use the method with which he/she is most familiar. Creation of a bowel stoma during primary management of a perineal tear
is not indicated. Daily cleaning of the area under running water is recommended, particularly after bowel movements. Cleaning may be carried out either by rinsing or alternate cold and warm
water douches. Therapy should also include the postoperative use of laxatives over a period of at least 2 weeks. The patient must be informed about the impact of the injury on subsequent
births as well as the possibility of anal incontinence.
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Affiliation(s)
- Stephan Kropshofer
- Frauenheilkunde und Geburtshilfe, Tirol Kliniken GmbH, Innsbruck, Austria
| | | | - Kathrin Beilecke
- Klinik für Urogynäkologie, Alexianer Sankt Hedwig Kliniken Berlin GmbH, Berlin, Germany
| | - Andrea Frudinger
- Department of Gynecology, Medical University of Graz, Graz, Austria
| | | | - Engelbert Hanzal
- Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | - Hanns Helmer
- Department of Obstetrics and Maternal-fetal Medicine, Medical University of Vienna, Vienna, Austria
| | | | | | | | | | - Annette Kuhn
- Urogynaecology, Inselspital Universitatsspital Bern, Bern, Switzerland
| | - Johann Pfeifer
- Department of Surgery, Medical University of Graz, Graz, Austria
| | | | - Karl Tamussino
- Department of Gynecology, Medical University of Graz, Graz, Austria
| | - Wolfgang Umek
- Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | - Dieter Kölle
- Abteilung Gynäkologie, Sanatorium Hera, Vienna, Austria
| | - Michael Abou-Dakn
- Klinik für Gynäkologie, St Joseph Krankenhaus Berlin-Tempelhof, Berlin, Germany
| | - Boris Gabriel
- Klinik für Gynäkologie und Geburtshilfe, Josefs Hospital Wiesbaden, Wiesbaden, Germany
| | | | - Gunda Pristauz-Telsnigg
- Abteilung Frauenheilkunde und Geburtshilfe, Landeskrankenhaus Feldbach Fürstenfeld, Feldbach, Austria
| | - Petra Welskop
- Österreichisches Hebammengremium, Innsbruck, Austria
| | - Werner Bader
- Gynäkologie und Geburtshilfe, Klinikum Bielefeld, Bielefeld, Germany
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3
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Nurse- and Pelvic Floor Physical Therapist-Led Bowel Training in Patients With Fecal Incontinence in a Tertiary Care Center. Gastroenterol Nurs 2021; 44:39-46. [PMID: 33538522 DOI: 10.1097/sga.0000000000000498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 10/07/2019] [Indexed: 11/25/2022] Open
Abstract
Little is known about nurse- and pelvic floor physical therapist-led bowel training in fecal incontinence after previous conservative management has been deemed unsatisfactory. The objective of this study was to evaluate combined nurse- and physical therapist-led bowel training sessions in a tertiary care center. This was a prospective, cross-sectional study. All patients with fecal incontinence between 2015 and 2016 with and without previous conservative management were included. Combined conservative treatment was defined as the use of stool-bulking agents (psyllium fibers) with or without antidiarrheal medication (loperamide) in combination with biofeedback or pelvic floor muscle training. Questionnaires regarding fecal incontinence (Vaizey incontinence score) and quality of life (Short Form Health Survey-36) were used. A decrease in the Vaizey incontinence score of 5 or more points was deemed to be clinically significant. Vaizey incontinence scores in all 50 patients decreased from 14.7 (SD = 4.5) to 9.9 (SD = 4.8) at follow-up (p < .001). Forty percent of patients reported an improvement in their Vaizey incontinence score (change of 5 or more points). Improvement was noted in those with and without previous treatment. Quality of life improved significantly. The limitation of the study includes lack of a standardized treatment protocol. Fecal incontinence reduced after nurse- and physical therapist-led bowel training sessions in patients with and without previous treatment, increasing their quality of life.
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D'Amico F, Wexner SD, Vaizey CJ, Gouynou C, Danese S, Peyrin-Biroulet L. Tools for fecal incontinence assessment: lessons for inflammatory bowel disease trials based on a systematic review. United European Gastroenterol J 2020; 8:886-922. [PMID: 32677555 DOI: 10.1177/2050640620943699] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Fecal incontinence is a disabling condition affecting up to 20% of women. OBJECTIVE We investigated fecal incontinence assessment in both inflammatory bowel disease and non-inflammatory bowel disease patients to propose a diagnostic approach for inflammatory bowel disease trials. METHODS We searched on Pubmed, Embase and Cochrane Library for all studies on adult inflammatory bowel disease and non-inflammatory bowel disease patients reporting data on fecal incontinence assessment from January 2009 to December 2019. RESULTS In total, 328 studies were included; 306 studies enrolled non-inflammatory bowel disease patients and 22 studies enrolled inflammatory bowel disease patients. In non-inflammatory bowel disease trials the most used tools were the Wexner score, fecal incontinence quality of life questionnaire, Vaizey score and fecal incontinence severity index (in 187, 91, 62 and 33 studies). Anal manometry was adopted in 41.2% and endoanal ultrasonography in 34.0% of the studies. In 142 studies (46.4%) fecal incontinence evaluation was performed with a single instrument, while in 64 (20.9%) and 100 (32.7%) studies two or more instruments were used. In inflammatory bowel disease studies the Wexner score, Vaizey score and inflammatory bowel disease quality of life questionnaire were the most commonly adopted tools (in five (22.7%), five (22.7%) and four (18.2%) studies). Anal manometry and endoanal ultrasonography were performed in 45.4% and 18.2% of the studies. CONCLUSION Based on prior validation and experience, we propose to use the Wexner score as the first step for fecal incontinence assessment in inflammatory bowel disease trials. Anal manometry and/or endoanal ultrasonography should be taken into account in the case of positive questionnaires.
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Affiliation(s)
- Ferdinando D'Amico
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston USA
| | | | - Célia Gouynou
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Silvio Danese
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
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5
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Simillis C, Lal N, Pellino G, Baird D, Nikolaou S, Kontovounisios C, Smith JJ, Tekkis PP. A systematic review and network meta-analysis comparing treatments for faecal incontinence. Int J Surg 2019; 66:37-47. [PMID: 31022519 DOI: 10.1016/j.ijsu.2019.04.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 03/24/2019] [Accepted: 04/16/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although numerous treatments exist for fecal incontinence (FI), no consensus exists on the best treatment strategy. The aim was to review the literature and to compare the clinical outcomes and effectiveness of treatments available for FI. MATERIALS AND METHOD A systematic literature review was performed, from inception to May 2018, of the following databases: MEDLINE, EMBASE, Science Citation Index Expanded, Cochrane Library. The search terms used were "faecal incontinence" and "treatment". Only randomized controlled trials (RCTs) comparing treatments for FI were considered. A Bayesian network meta-analysis was performed using the Markov chain Monte Carlo method. RESULT Forty-seven RCTs were included comparing 37 treatments and reporting on 3748 participants. No treatment ranked best or worst with high probability for any outcome of interest. No significant difference was identified between treatments for frequency of FI per week, or in changing the resting pressure, maximum resting pressure, squeeze pressure, and maximum squeeze pressure. Radiofrequency resulted in more adverse events compared to placebo. Sacral nerve stimulation (SNS) and zinc-aluminium improved the fecal incontinence quality of life questionnaire (FIQL) lifestyle, coping, and embarrassment domains compared to placebo. Transcutaneous posterior tibial nerve stimulation (TPTNS) improved the FIQL embarrassment domain compared to placebo. Autologous myoblasts and zinc-aluminium improved the FIQL depression domain compared to placebo. SNS, artificial bowel sphincter (ABS), and zinc-aluminium significantly improved incontinence scores compared to placebo. Injection of non-animal stabilized hyaluronic acid/dextranomer (NASHA/Dx) resulted in more patients with ≥50% reduction in FI episodes compared to placebo. CONCLUSION SNS, ABS, TPTNS, NASHA/Dx, zinc-aluminium, and autologous myoblasts resulted in isolated improvements in specific outcomes of interest. No difference was identified in incontinence episodes, no treatment ranked best persistently or persistently improved outcomes, and many included treatments did not significantly benefit patients compared to placebo. Large multicentre RCTs with long-term follow-up and standardized inclusion criteria and outcome measures are needed.
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Affiliation(s)
- Constantinos Simillis
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK; Department of Surgery and Cancer, Imperial College, London, UK.
| | - Nikhil Lal
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK; Department of Surgery and Cancer, Imperial College, London, UK
| | - Gianluca Pellino
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Daniel Baird
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK; Department of Surgery and Cancer, Imperial College, London, UK
| | - Stella Nikolaou
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK; Department of Surgery and Cancer, Imperial College, London, UK
| | - Christos Kontovounisios
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK; Department of Surgery and Cancer, Imperial College, London, UK
| | - Jason J Smith
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK; Department of Surgery and Cancer, Imperial College, London, UK
| | - Paris P Tekkis
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK; Department of Surgery and Cancer, Imperial College, London, UK
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6
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Lal N, Simillis C, Slesser A, Kontovounisios C, Rasheed S, Tekkis PP, Tan E. A systematic review of the literature reporting on randomised controlled trials comparing treatments for faecal incontinence in adults. Acta Chir Belg 2019; 119:1-15. [PMID: 30644337 DOI: 10.1080/00015458.2018.1549392] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AIM To perform a review of the literature reporting on randomised controlled trials (RCTs) comparing treatments for faecal incontinence (FI) in adults. METHODS A literature search of MEDLINE, Embase, Science Citation Index Expanded and Cochrane was performed in order to identify RCTs reporting on treatments for FI. RESULTS The review included 60 RCTs reporting on 4838 patients with a mean age ranging from 36.8 to 88 years. From the included RCTs, 32 did not identify a significant difference between the treatments compared. Contradictory results were identified in RCTs comparing percutaneous posterior tibial nerve stimulation and transcutaneous tibial nerve stimulation versus sham stimulation, biofeedback-pelvic floor muscle training (BF-PFMT) versus PFMT, and between bulking agents such as PTQTM versus Durasphere®. In two separate RCTs, combination treatment of amplitude-modulated medium frequency stimulation and electromyography-biofeedback (EMG-BF), was noted to be superior to EMG-BF and low-frequency electrical stimulation alone. Combination of non-surgical treatments such as BF with sphincteroplasty significantly improved continence scores compared to sphincteroplasty alone. Surgical treatments were associated with higher rates of serious adverse events compared to non-surgical interventions. CONCLUSIONS The current evidence has not identified significant differences between treatments for FI, and where differences were identified, the results were contradictory between RCTs.
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Affiliation(s)
- Nikhil Lal
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Constantinos Simillis
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
| | - Alistair Slesser
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
| | - Christos Kontovounisios
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Shahnawaz Rasheed
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
| | - Paris P. Tekkis
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
| | - Emile Tan
- Department of Colorectal Surgery, Singapore General Hospital, Singapore, Singapore
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7
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Bocchini R, Chiarioni G, Corazziari E, Pucciani F, Torresan F, Alduini P, Bassotti G, Battaglia E, Ferrarini F, Galeazzi F, Londoni C, Rossitti P, Usai Satta P, Iona L, Marchi S, Milazzo G, Altomare DF, Barbera R, Bove A, Calcara C, D'Alba L, De Bona M, Goffredo F, Manfredi G, Naldini G, Neri MC, Turco L, La Torre F, D'Urso AP, Berni I, Balestri MA, Busin N, Boemo C, Bellini M. Pelvic floor rehabilitation for defecation disorders. Tech Coloproctol 2019; 23:101-115. [PMID: 30631977 DOI: 10.1007/s10151-018-1921-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 12/26/2018] [Indexed: 12/17/2022]
Abstract
Pelvic floor rehabilitation is frequently recommended for defecation disorders, in both constipation and fecal incontinence. However, the lack of patient selection, together with the variety of rehabilitation methods and protocols, often jeopardize the results of this approach, causing difficulty in evaluating outcomes and addressing proper management, and above all, in obtaining scientific evidence for the efficacy of these methods for specific indications. The authors represent different gastroenterological and surgical scientific societies in Italy, and their aim was to identify the indications and agree on treatment protocols for pelvic floor rehabilitation of patients with defecation disorders. This was achieved by means of a modified Delphi method, utilizing a working team (10 members) which developed the statements and a consensus group (15 members, different from the previous ones) which voted twice also suggesting modifications of the statements.
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Affiliation(s)
- R Bocchini
- Gastroenterology Unit, Malatesta Novello Private Hospital, Cesena, Italy.
| | - G Chiarioni
- RFF Division of Gastroenterology, University of Verona, Verona, Italy.,Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - E Corazziari
- Department of Gastroenterology, Istituto Clinico Humanitas, Milan, Italy
| | - F Pucciani
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - F Torresan
- Department of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - P Alduini
- Gastroenterology and Endoscopy Unit, San Luca Hospital, Lucca, Italy
| | - G Bassotti
- Gastroenterology and Hepatology Section, Department of Medicine, University of Perugia Medical School, Perugia, Italy
| | - E Battaglia
- Gastroenterology and Endoscopy Unit, Cardinal Massaia Hospital, Asti, Italy
| | - F Ferrarini
- Endoscopy Unit, San Clemente Private Hospital, Mantua, Italy
| | - F Galeazzi
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - C Londoni
- Gastroenterology and Endoscopy Unit, ASST "Maggiore", Crema, Cremona, Italy
| | - P Rossitti
- Gastroenterology Unit, S. Maria della Misericordia Hospital, Udine, Italy
| | - P Usai Satta
- Gastroenterology Unit, G. Brotzu Hospital, Cagliari, Italy
| | - L Iona
- Early Rehabilitation Department, S. Maria della Misericordia Hospital, Udine, Italy
| | - S Marchi
- Gastrointestinal Unit, Departmentt. of General Surgery, University of Pisa, Pisa, Italy
| | - G Milazzo
- U.O.Lungodegenza e Medicina, Ospedale Vittorio Emanuele III, Salemi, Tp, Italy
| | - D F Altomare
- Department of Emergency and Organ Transplantation (DETO) and Interdepart mental Research Center for Pelvic Floor Dysfunction (CIRPAP), University Aldo Moro, Policlinico, Bari, Italy
| | - R Barbera
- San Giuseppe Multimedica Hospital, Milan, Italy
| | - A Bove
- Gastroenterology and Endoscopy Unit, Department of Gastroenterology, A. Cardarelli Hospital, Naples, Italy
| | - C Calcara
- Gastroenterology Unit, SSVD Gastroenterologia, Ospedale SS Trinità, Borgomanero, No, Italy
| | - L D'Alba
- Gastroenterology and Digestive Endoscopy Unit, San Giovanni-Addolorata Hospital, Rome, Italy
| | - M De Bona
- Gastroenterology and Endoscopy Unit, Feltre Hospital, Feltre, Bl, Italy
| | - F Goffredo
- Gastroenterology and Endoscopy Unit, San Camillo-Forlanini Hospital, Rome, Italy
| | - G Manfredi
- Department of Gastroenterology and Digestive Endoscopy, Crema Hospital, ASST CREMA, Crema, Italy
| | - G Naldini
- Proctological and Perineal Surgery Unit, Cisanello University Hospital, Pisa, Italy
| | - M C Neri
- Gastroenterology Unit, Geriatric Institute "Pio Albergo Trivulzio", Milan, Italy
| | - L Turco
- Department of Digestive Physiopathology, Healte Center "Cittadella della Salute", Lecce, Italy
| | - F La Torre
- Department of Surgical Sciences, University "La Sapienza", Policlinico Umberto I, Rome, Italy
| | | | - I Berni
- Rehabilitation Department, San Luca Hospital, Lucca, Italy
| | - M A Balestri
- Proctological and Perineal Surgery Unit, Cisanello University Hospital, Pisa, Italy
| | - N Busin
- Rehabilitation Department, Villa Igea Private Hospital, Forlì, Italy
| | - C Boemo
- Early Rehabilitation Department, S. Maria della Misericordia Hospital, Udine, Italy
| | - M Bellini
- Gastrointestinal Unit, Department of General Surgery, University of Pisa, Pisa, Italy
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8
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Heymen S, Palsson O, Simren M, Whitehead WE. Patient preferences for endpoints in fecal incontinence treatment studies. Neurogastroenterol Motil 2017; 29. [PMID: 28271624 DOI: 10.1111/nmo.13032] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 12/22/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Randomized controlled trials of treatments for fecal incontinence (FI) are difficult to compare because case definitions and study endpoints vary. Our aims were to assess patient perspectives on the case definition for FI and how treatment success should be measured. METHODS In Phase 1, 28 FI patients participated in anonymous on-line focus groups, and in Phase 2, 186 people with FI, stratified by gender, race, and age completed an online survey. KEY RESULTS Focus group participants described frequency and urgency as the most important characteristics for defining FI. Most (80%) thought staining of underwear constitutes FI, but only 33% thought gas leakage was FI. When asked how the success of treatment should be defined, 77% said by a reduction in frequency or complete cure, but less than half thought a 50% reduction in frequency was enough. When asked how much reduction would be needed, responses averaged 80%. The Phase 2 survey confirmed that frequency, urgency, and intestinal discomfort are the most important characteristics for case definition, and that success should be defined by at least a 75% decrease in frequency. A 50% reduction was an acceptable endpoint for 58% overall but only 26% for those aged ≥65. "Adequate relief" was acceptable to 78%. CONCLUSIONS AND INFERENCES Inclusion criteria for trials should specify a minimum frequency of FI. Most patients would require a ≥75% reduction in FI frequency to call a treatment successful but young adults and those with more severe FI would accept a ≥50% reduction as meaningful.
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Affiliation(s)
- S Heymen
- Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - O Palsson
- Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - M Simren
- Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - W E Whitehead
- Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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9
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Markland AD, Jelovsek JE, Whitehead WE, Newman DK, Andy UU, Dyer K, Harm-Ernandes I, Cichowski S, McCormick J, Rardin C, Sutkin G, Shaffer A, Meikle S. Improving biofeedback for the treatment of fecal incontinence in women: implementation of a standardized multi-site manometric biofeedback protocol. Neurogastroenterol Motil 2017; 29:10.1111/nmo.12906. [PMID: 27453154 PMCID: PMC5198255 DOI: 10.1111/nmo.12906] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 06/20/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Standardized training and clinical protocols using biofeedback for the treatment of fecal incontinence (FI) are important for clinical care. Our primary aims were to develop, implement, and evaluate adherence to a standardized protocol for manometric biofeedback to treat FI. METHODS In a Pelvic Floor Disorders Network (PFDN) trial, participants were enrolled from eight PFDN clinical centers across the United States. A team of clinical and equipment experts developed biofeedback software on a novel tablet computer platform for conducting standardized anorectal manometry with separate manometric biofeedback protocols for improving anorectal muscle strength, sensation, and urge resistance. The training protocol also included education on bowel function, anal sphincter exercises, and bowel diary monitoring. Study interventionists completed online training prior to attending a centralized, standardized certification course. For the certification, expert trainers assessed the ability of the interventionists to perform the protocol components for a paid volunteer who acted as a standardized patient. Postcertification, the trainers audited interventionists during trial implementation to improve protocol adherence. KEY RESULTS Twenty-four interventionists attended the in-person training and certification, including 46% advanced practice registered nurses (11/24), 50% (12/24) physical therapists, and 4% physician assistants (1/24). Trainers performed audio audits for 88% (21/24), representing 84 audited visits. All certified interventionists met or exceeded the prespecified 80% pass rate for the audit process, with an average passing rate of 93%. CONCLUSIONS & INFERENCES A biofeedback protocol can be successfully imparted to experienced pelvic floor health care providers from various disciplines. Our process promoted high adherence to a standard protocol and is applicable to many clinical settings.
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Affiliation(s)
- Alayne D. Markland
- Department of Medicine, Division of Gerontology, Geriatrics and Palliative Care, University of Alabama at Birmingham, Birmingham, AL & the Birmingham Veterans Affairs Medical Center, Geriatric Research, Education, and Clinical Center
| | - J. Eric Jelovsek
- Obstetrics, Gynecology & Women’s Health Institute, Cleveland Clinic, Cleveland, OH
| | - William E. Whitehead
- Department of Medicine (Division of Gastroenterology and Hepatology), and Department of Obstetrics and Gynecology (Division of Urogynecology) University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Diane K. Newman
- Department of Surgery, Division of Urology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Uduak U. Andy
- Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Keisher Dyer
- Department of Obstetrics and Gynecology Kaiser Permanente, San Diego, CA
| | - Ingrid Harm-Ernandes
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - Sara Cichowski
- Departments of Obstetrics and Gynecology and Surgery, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Jeannine McCormick
- Department of Medicine, Division of Gerontology, Geriatrics and Palliative Care, University of Alabama at Birmingham, Birmingham, AL & the Birmingham Veterans Affairs Medical Center, Geriatric Research, Education, and Clinical Center
| | - Charles Rardin
- Department of Obstetrics and Gynecology, Alpert Medical School of Brown University, Providence, RI
| | - Gary Sutkin
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Susan Meikle
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
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10
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Abstract
Pelvic floor dysfunction and fecal incontinence is a common and debilitating condition in women, particularly as women age, and often goes under-reported to health care providers. It is important for providers to ask patients about possible symptoms. An algorithm for evaluation and treatment is presented. Current and future therapies are described and discussed.
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11
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Fecal Incontinence: Etiology, Diagnosis, and Management. J Gastrointest Surg 2015; 19:1910-21. [PMID: 26268955 DOI: 10.1007/s11605-015-2905-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 07/27/2015] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Fecal incontinence is a debilitating condition affecting primarily the elderly. Many patients suffer in silence resulting in both underdiagnosis and undertreatment often culminating in an overall poor quality of life. METHODS We sought to review the etiology, diagnosis, and treatment of fecal incontinence based on current literature. Additionally, newer treatment methods such as Solesta will be evaluated. RESULTS There are many diagnostic modalities available to assess the degree and severity of the patient's incontinence; however, a thorough history and physical exam is critical. Initial attempts at treatment focus on medical management primarily through stool texture modification with the aid of bulking agents. Failure of medical therapy is often followed by a graded increase in the complexity and invasiveness of the available treatment options. The selection of the most appropriate surgical option, such as overlapping sphincteroplasty and neuromodulation, is multifactorial involving both surgeon and patient-related factors. Neuromodulation has received increased attention in the last decade due to its documented therapeutic success, and newer office-based procedures, such as the Solesta injection, are showing promising results in properly selected patients. Finally, diversion remains an option for select patients who have failed all other therapies. CONCLUSION The etiology of fecal incontinence is multifactorial, involving a complex interplay between stool consistency and anatomic integrity. The diagnosis and treatment of fecal incontinence continue to evolve and are showing promising results.
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Rao SS, Benninga MA, Bharucha AE, Chiarioni G, Di Lorenzo C, Whitehead WE. ANMS-ESNM position paper and consensus guidelines on biofeedback therapy for anorectal disorders. Neurogastroenterol Motil 2015; 27:594-609. [PMID: 25828100 PMCID: PMC4409469 DOI: 10.1111/nmo.12520] [Citation(s) in RCA: 153] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 12/30/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Anorectal disorders such as dyssynergic defecation, fecal incontinence, levator ani syndrome, and solitary rectal ulcer syndrome are common, and affect both the adult and pediatric populations. Although they are treated with several treatment approaches, over the last two decades, biofeedback therapy using visual and verbal feedback techniques has emerged as an useful option. Because it is safe, it is commonly recommended. However, the clinical efficacy of biofeedback therapy in adults and children is not clearly known, and there is a lack of critical appraisal of the techniques used and the outcomes of biofeedback therapy for these disorders. PURPOSE The American Neurogastroenterology and Motility Society and the European Society of Neurogastroenterology and Motility convened a task force to examine the indications, study performance characteristics, methodologies used, and the efficacy of biofeedback therapy, and to provide evidence-based recommendations. Based on the strength of evidence, biofeedback therapy is recommended for the short-term and long-term treatment of constipation with dyssynergic defecation (Level I, Grade A), and for the treatment of fecal incontinence (Level II, Grade B). Biofeedback therapy may be useful in the short-term treatment of Levator Ani Syndrome with dyssynergic defecation (Level II, Grade B), and solitary rectal ulcer syndrome with dyssynergic defecation (Level III, Grade C), but the evidence is fair. Evidence does not support the use of biofeedback for the treatment of childhood constipation (Level 1, Grade D).
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Affiliation(s)
- Satish S.C. Rao
- Section of Gastroenterology/Hepatology, Georgia Regents University, Augusta, USA
| | - Marc A Benninga
- Department of Pediatric Gastroenterology, Emma Children’s Hospital/Academic Medical Centre, Amsterdam, The Netherlands
| | - Adil E Bharucha
- Department of Gastroenterology, Mayo Clinic, Rochester, MN, USA
| | - Giuseppe Chiarioni
- Division of Gastroenterology of the University of Verona, A.O.U.I. Verona, Italy and Division of Gastroenterology/Hepatology, University of North Carolina, Chapel Hill, NC, USA
| | - Carlo Di Lorenzo
- Department of Pediatric Gastroenterology, Nationwide Children’s Hospital, Columbus, OH, USA
| | - William E Whitehead
- Division of Gastroenterology/Hepatology, University of North Carolina, Chapel Hill, NC, USA
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13
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Cohen-Zubary N, Gingold-Belfer R, Lambort I, Wasserberg N, Krissi H, Levy S, Niv Y, Dickman R. Home electrical stimulation for women with fecal incontinence: a preliminary randomized controlled trial. Int J Colorectal Dis 2015; 30:521-8. [PMID: 25619464 DOI: 10.1007/s00384-015-2128-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE The purpose of this study is to compare the effectiveness and cost of home electrical stimulation and standardized biofeedback training in females with fecal incontinence METHODS Thirty-six females suffering from fecal incontinence were randomized into two groups, matched for mean age (67.45 ± 7.2 years), mean body mass index (kg/m2) (26.2 ± 3.9), mean disease duration (4.1 ± 0.8 years), mean number of births (2.7 ± 1.3), and reports of obstetric trauma (25%). Questionnaires were used to evaluate their demographics, medical, and childbearing history. Subjects were randomized to home electrical stimulation or standardized biofeedback training for a period of 6 weeks. Subjective outcome measures included the frequency of fecal, urine, and gas incontinence by visual analog scale, Vaizey incontinence score, and subjects' levels of fecal incontinence related anxiety. Objective outcome measures included pelvic floor muscle strength assessed by surface electromyography. We also compared the cost of each treatment modality. RESULTS Only females who received home electrical stimulation (HES) reported a significant improvement in Vaizey incontinence score (p = 0.001), anxiety (p = 0.046), and in frequency of leaked solid stool (p = 0.013). A significant improvement in pelvic floor muscle strength was achieved by both groups. HES was much cheaper compared to the cost of standardized biofeedback training (SBT) (US $100 vs. US $220, respectively). Our study comprised a small female population, and the study endpoints did not include objective measures of anorectal function test, such as anorectal manometry, before and after treatment. CONCLUSIONS Home electrical stimulation may offer an alternative to standardized biofeedback training as it is effective and generally well-tolerated therapy for females with fecal incontinence.
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14
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Kuo LJ, Lin YC, Lai CH, Lin YK, Huang YS, Hu CC, Chen SC. Improvement of fecal incontinence and quality of life by electrical stimulation and biofeedback for patients with low rectal cancer after intersphincteric resection. Arch Phys Med Rehabil 2015; 96:1442-7. [PMID: 25838018 DOI: 10.1016/j.apmr.2015.03.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 03/11/2015] [Accepted: 03/19/2015] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To assess the efficacy and benefits of pelvic rehabilitation programs in terms of functional outcomes and quality of life for patients with fecal incontinence and defecation disorders after rectal cancer surgery. DESIGN Prospective, observational study. SETTING University hospital physiotherapy clinics. PARTICIPANTS Patients (N=32) who experienced fecal incontinence after sphincter-saving surgery with the intersphincteric resection (ISR) technique and could follow and cooperate with the treatment schedule were included in the present study. INTERVENTIONS Pelvic rehabilitation programs included electrical stimulation (ES) and biofeedback (BF). MAIN OUTCOME MEASURES Functional results, Wexner score, and anorectal manometry were used to assess the clinical outcomes of rehabilitation treatment. RESULTS Maximum squeeze pressure improved after rehabilitation training (P=.014). There were no statistical differences in resting pressure, resting muscle electromyography, and maximum squeeze electromyography (P=.061, P=.76, and P=.99, respectively). The mean stool frequency was 18.8 per 24 hours before the pelvic intervention program and 7.8 per 24 hours after ES and BF training (P<.001). Of the 32 patients, 27 required antidiarrheal medications before treatment, and after completion of the training, only 9 patients still needed antidiarrheal medications (P<.001). Significant improvements were observed in the Wexner score (17.74 vs 12.93; P<.001). CONCLUSIONS Our data show that ES and BF are effective in the treatment of fecal incontinence, leading to improvement of quality of life for patients with low rectal cancer after ISR.
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Affiliation(s)
- Li-Jen Kuo
- Division of General Surgery, Taipei Medical University Hospital, Taipei, Taiwan; Department of Surgery, Taipei Medical University Hospital, Taipei, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
| | - Yu-Ching Lin
- Department of Physical Medicine and Rehabilitation, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chien-Hung Lai
- Department of Physical Medicine and Rehabilitation, Taipei Medical University Hospital, Taipei, Taiwan; Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yen-Kuang Lin
- Biostatistics and Research Consultation Center, Taipei Medical University, Taipei, Taiwan
| | - Yu-Shih Huang
- Department of Surgery, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chia-Chen Hu
- Department of Physical Medicine and Rehabilitation, Taipei Medical University Hospital, Taipei, Taiwan
| | - Shih-Ching Chen
- Department of Physical Medicine and Rehabilitation, Taipei Medical University Hospital, Taipei, Taiwan; Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
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15
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Steele SR, Varma MG, Prichard D, Bharucha AE, Vogler SA, Erdogan A, Rao SSC, Lowry AC, Lange EO, Hall GM, Bleier JIS, Senagore AJ, Maykel J, Chan SY, Paquette IM, Audett MC, Bastawrous A, Umamaheswaran P, Fleshman JW, Caton G, O'Brien BS, Nelson JM, Steiner A, Garely A, Noor N, Desrosiers L, Kelley R, Jacobson NS. The evolution of evaluation and management of urinary or fecal incontinence and pelvic organ prolapse. Curr Probl Surg 2015; 52:17-75. [PMID: 25919203 DOI: 10.1067/j.cpsurg.2015.01.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 01/29/2015] [Indexed: 12/13/2022]
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16
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Aigmueller T, Bader W, Beilecke K, Elenskaia K, Frudinger A, Hanzal E, Helmer H, Huemer H, van der Kleyn M, Koelle D, Kropshofer S, Pfeiffer J, Reisenauer C, Tammaa A, Tamussino K, Umek W. Management of 3rd and 4th Degree Perineal Tears after Vaginal Birth. German Guideline of the German Society of Gynecology and Obstetrics (AWMF Registry No. 015/079, October 2014). Geburtshilfe Frauenheilkd 2015; 75:137-144. [PMID: 26157195 PMCID: PMC4477621 DOI: 10.1055/s-0034-1396323] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
- T. Aigmueller
- Universitätsklinik für Frauenheilkunde und Geburtshilfe Graz, Österreich
| | | | - K. Beilecke
- Klinik St. Hedwig, KH Barmherzige Brüder, Regensburg
| | | | - A. Frudinger
- Universitätsklinik für Frauenheilkunde und Geburtshilfe Graz, Österreich
| | - E. Hanzal
- Medizinische Universität Wien, Wien, Österreich
| | - H. Helmer
- Medizinische Universität Wien, Wien, Österreich
| | - H. Huemer
- Klinikum Wels-Grieskirchen, Österreich
| | | | | | - S. Kropshofer
- Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - J. Pfeiffer
- Universitätsklinik für Frauenheilkunde und Geburtshilfe Graz, Österreich
| | | | - A. Tammaa
- Wilhelminenspital Wien, Wien, Österreich
| | - K. Tamussino
- Universitätsklinik für Frauenheilkunde und Geburtshilfe Graz, Österreich
| | - W. Umek
- Medizinische Universität Wien, Wien, Österreich
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Whitehead WE, Rao SSC, Lowry A, Nagle D, Varma M, Bitar KN, Bharucha AE, Hamilton FA. Treatment of fecal incontinence: state of the science summary for the National Institute of Diabetes and Digestive and Kidney Diseases workshop. Am J Gastroenterol 2015; 110:138-46; quiz 147. [PMID: 25331348 DOI: 10.1038/ajg.2014.303] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Accepted: 08/05/2014] [Indexed: 12/11/2022]
Abstract
This is the second of a two-part summary of a National Institutes of Health conference on fecal incontinence (FI) that summarizes current treatments and identifies research priorities. Conservative medical management consisting of patient education, fiber supplements or antidiarrheals, behavioral techniques such as scheduled toileting, and pelvic floor exercises restores continence in up to 25% of patients. Biofeedback, often recommended as first-line treatment after conservative management fails, produces satisfaction with treatment in up to 76% and continence in 55%; however, outcomes depend on the skill of the therapist, and some trials are less favorable. Electrical stimulation of the anal mucosa is ineffective, but continuous electrical pulsing of sacral nerves produces a ≥50% reduction in FI frequency in a median 73% of patients. Tibial nerve electrical stimulation with needle electrodes is promising but remains unproven. Sphincteroplasty produces short-term clinical improvement in a median 67%, but 5-year outcomes are poor. Injecting an inert bulking agent around the anal canal led to ≥50% reductions of FI in up to 53% of patients. Colostomy is used as a last resort because of adverse effects on quality of life. Several new devices are under investigation but not yet approved. FI researchers identify the following priorities for future research: (1) trials comparing the effectiveness, safety, and cost of current therapies; (2) studies addressing barriers to consulting for care; and (3) translational research on regenerative medicine. Unmet patient needs include FI in special populations (e.g., neurological disorders and nursing home residents) and improvements in behavioral treatments.
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Affiliation(s)
- William E Whitehead
- 1] Division of Gastroenterology and Hepatology, Department of Medicine, Chapel Hill, North Carolina, USA [2] Division of Urogynecology and Reconstructive Pelvic Floor Surgery, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Satish S C Rao
- Department of Gastroenterology, Georgia Regents University, Augusta, Georgia, USA
| | - Ann Lowry
- Colon and Rectal Surgery Associates, Ltd., St. Paul, Minnesota, USA
| | - Deborah Nagle
- Department of Colon and Rectal Surgery, Harvard Medical Faculty Physicians at Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Madhulika Varma
- Section of Colorectal Surgery, University of California, San Francisco, California, USA
| | - Khalil N Bitar
- Department of Regenerative Medicine, Wake Forest Institute for Regenerative Medicine, Winston Salem, North Carolina, USA
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Frank A Hamilton
- National Institutes of Diabetes, Digestive and Kidney Diseases, National Institute of Health, Bethesda, Maryland, USA
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18
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Borycka-Kiciak K, Wawiernia K, Namysł J, Garstka-Namysł K, Tarnowski W. Role of electromyography and functional electrical stimulation in the treatment of anorectal diseases. POLISH JOURNAL OF SURGERY 2015; 87:194-202. [DOI: 10.1515/pjs-2015-0044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Indexed: 11/15/2022]
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Abstract
Fecal incontinence (FI) is a prevalent problem that can drastically affect quality of life. Pelvic floor rehabilitation is an important first-line treatment for patients with FI, and many published case reports and a small number of randomized controlled trials (RCTs) provide limited evidence for its efficacy. Pelvic floor rehabilitation approaches to the treatment of FI include pelvic floor muscle training, biofeedback, and volumetric training with rectal balloon catheters. Various forms of external electrical stimulation have also been described and may be of added benefit. Behavioral bowel retraining is an important part of a good rehabilitative approach as well. Pelvic floor rehabilitation treatment for FI is thought to be effective and safe, with reported success rates in a majority of studies at 50 to 80%. Many more high-quality RCTs are needed to define optimal treatment protocols.
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Affiliation(s)
- Kelly M Scott
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas
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20
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Melão S, dos Reis Lima DM, Ratin RF, Kurachi G, Rizzardi K, Schuster M, Sagae UE. Effectiveness of treatment using fecal incontinence biofeedback isolated or associated with electrical stimulation. JOURNAL OF COLOPROCTOLOGY 2014. [DOI: 10.1016/j.jcol.2014.08.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Abstract
Fecal incontinence (FI) is a multifactorial disorder that imposes considerable social and economic burdens. The aim of this article is to provide an overview of current and emerging treatment options for FI. A MEDLINE search was conducted for English-language articles related to FI prevalence, etiology, diagnosis, and treatment published from January 1, 1990 through June 1, 2013. The search was extended to unpublished trials on ClinicalTrials.gov and relevant publications cited in included articles. Conservative approaches, including dietary modifications, medications, muscle-strengthening exercises, and biofeedback, have been shown to provide short-term benefits. Transcutaneous electrical stimulation was considered ineffective in a randomized clinical trial. Unlike initial studies, sacral nerve stimulation has shown reasonable short-term effectiveness and some complications. Dynamic graciloplasty and artificial sphincter and bowel devices lack randomized controlled trials and have shown inconsistent results and high rates of explantation. Of injectable bulking agents, dextranomer microspheres in non-animal stabilized hyaluronic acid (NASHA Dx) has shown significant improvement in incontinence scores and frequency of incontinence episodes, with generally mild adverse effects. For the treatment of FI, conservative measures and biofeedback therapy are modestly effective. When conservative therapies are ineffective, invasive procedures, including sacral nerve stimulation, may be considered, but they are associated with complications and lack randomized, controlled trials. Bulking agents may be an appropriate alternative therapy to consider before more aggressive therapies in patients who fail conservative therapies.
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22
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Abstract
Anal incontinence (AI) in adults is a troublesome condition that negatively impacts upon quality of life and results in significant embarrassment and social isolation. The conservative management of AI is the first step and targets symptomatic relief. The reported significant improvement with conservative treatments for AI is close to 25% and involves prescribed changes in lifestyle habits, a reduced intake of foods that may cause or aggravate diarrhea or rectal urgency, and the use of specific anti-diarrheal agents. The use of a mechanical barrier in the form of an anal plug and the outcomes and principles of pelvic kinesitherapies and biofeedback options are outlined. This review discusses a gastroenterologist's approach towards conservative therapy in patients referred with anal incontinence.
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Affiliation(s)
- Dan Carter
- Department of Gastroenterology, Chaim Sheba Medical Center, Israel
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23
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Damon H, Siproudhis L, Faucheron JL, Piche T, Abramowitz L, Eléouet M, Etienney I, Godeberge P, Valancogne G, Denis A, Mion F, Schott AM. Perineal retraining improves conservative treatment for faecal incontinence: a multicentre randomized study. Dig Liver Dis 2014; 46:237-42. [PMID: 24444704 DOI: 10.1016/j.dld.2013.11.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Revised: 10/02/2013] [Accepted: 11/01/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Anal incontinence is a frequent complaint that profoundly affects quality of life. Our aim was to determine whether perineal retraining gives additional benefits to standard medical treatment. METHODS Patients with anal incontinence and a Wexner score >4 were randomly assigned to standard conservative treatment (control) or perineal retraining, including biofeedback, in addition to standard treatments (biofeedback). Diaries, self-administered questionnaires and satisfaction scores quantified the benefits. Self-evaluated improvement was the primary outcome measure. A score ≥3 (in an improvement scale from -5 to +5) defined success. RESULTS Overall, 157 patients were included; 80 in the control group (75% females, mean age 60.1 ± 13.2 years) and 77 in the biofeedback group (79% females, mean age 61.9 ± 10.2 years). After a 4-month follow-up, the success rate was significantly higher in the biofeedback group (57% versus 37%; p<0.021). In the biofeedback group, daily stool frequency, leakage, and faecal urgency significantly decreased, and daily non-urgent perception of stool increased. Conversely, symptomatic scores and quality of life scales did not significantly differ between groups. In a multivariate model, the adjusted odds ratio showed that perineal retraining was significantly associated with a higher chance of self-rated improvement (adjusted Odd Ratio [95%CI]: 2.34 [1.14-4.80]; p=0.021). CONCLUSIONS Perineal retraining offers a moderate but significant benefit for patients suffering from anal incontinence.
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Affiliation(s)
- Henri Damon
- Hospices Civils de Lyon, Digestive Physiology, Lyon, France
| | | | | | | | | | | | | | | | | | | | - François Mion
- Hospices Civils de Lyon, Digestive Physiology, Lyon, France; University Lyon 1, France.
| | - Anne-Marie Schott
- Hospices Civils de Lyon, Epidemiology Unit, Lyon, France; University Lyon 1, France
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Koughnett JAMV, Wexner SD. Current management of fecal incontinence: Choosing amongst treatment options to optimize outcomes. World J Gastroenterol 2013; 19:9216-9230. [PMID: 24409050 PMCID: PMC3882396 DOI: 10.3748/wjg.v19.i48.9216] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Revised: 09/17/2013] [Accepted: 11/05/2013] [Indexed: 02/06/2023] Open
Abstract
The severity of fecal incontinence widely varies and can have dramatic devastating impacts on a person’s life. Fecal incontinence is common, though it is often under-reported by patients. In addition to standard treatment options, new treatments have been developed during the past decade to attempt to effectively treat fecal incontinence with minimal morbidity. Non-operative treatments include dietary modifications, medications, and biofeedback therapy. Currently used surgical treatments include repair (sphincteroplasty), stimulation (sacral nerve stimulation or posterior tibial nerve stimulation), replacement (artificial bowel sphincter or muscle transposition) and diversion (stoma formation). Newer augmentation treatments such as radiofrequency energy delivery and injectable materials, are minimally invasive tools that may be good options before proceeding to surgery in some patients with mild fecal incontinence. In general, more invasive surgical treatments are now reserved for moderate to severe fecal incontinence. Functional and quality of life related outcomes, as well as potential complications of the treatment must be considered and the treatment of fecal incontinence must be individualized to the patient. General indications, techniques, and outcomes profiles for the various treatments of fecal incontinence are discussed in detail. Choosing the most effective treatment for the individual patient is essential to achieve optimal outcomes in the treatment of fecal incontinence.
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Dehli T, Stordahl A, Vatten LJ, Romundstad PR, Mevik K, Sahlin Y, Lindsetmo RO, Vonen B. Sphincter training or anal injections of dextranomer for treatment of anal incontinence: a randomized trial. Scand J Gastroenterol 2013; 48:302-10. [PMID: 23298304 DOI: 10.3109/00365521.2012.758770] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The objective is to test if the injection of a bulking agent in the anal canal is superior to sphincter training with biofeedback in the treatment of anal incontinence. BACKGROUND Anal incontinence is traditionally treated with conservative measures, such as pads and constipating medicine. If this fails, sphincter training with biofeedback is often offered before more advanced surgical procedures are considered. The injection of a bulking agent in the anal canal is a relatively new and promising treatment option. METHODS In a randomized, controlled, evaluator-blinded trial, 126 adult patients with anal incontinence were randomly assigned to a transanal, submucosal injection of 4 x 1 mL of dextranomer in hyaluronic acid or to sphincter training with biofeedback. The primary outcome was severity of incontinence, evaluated by St Mark's score for incontinence (0 = continence to 24 = complete incontinence) assessed at 2 years after the start of treatment. A mixed models analysis was applied. RESULTS Of the 126 participants, 64 patients were randomly assigned to anal injections, and among them the mean St Mark's score improved from 12.9 (95% CI: 11.8-14.0) at baseline to 8.3 (95% CI: 6.7-9.8) at the end of follow up. Among the 62 patients who were assigned to sphincter training with biofeedback, there was a corresponding improvement in St Mark's score from 12.6 (95% CI: 11.4-13.8) to 7.2 (95% CI: 7.2-8.8). Comparisons of St Mark's scores between the groups showed no differences in effect between treatments. CONCLUSION The efficacy of anal injections and biofeedback in treating anal incontinence did not differ in this randomized, single-blinded, controlled trial.
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Affiliation(s)
- Trond Dehli
- Department of Gastrointestinal Surgery, University Hospital of North Norway, Tromsø, Norway.
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Vonthein R, Heimerl T, Schwandner T, Ziegler A. Electrical stimulation and biofeedback for the treatment of fecal incontinence: a systematic review. Int J Colorectal Dis 2013; 28:1567-77. [PMID: 23900652 PMCID: PMC3824723 DOI: 10.1007/s00384-013-1739-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/24/2013] [Indexed: 02/04/2023]
Abstract
PURPOSE This systematic review determines the best known form of biofeedback (BF) and/or electrical stimulation (ES) for the treatment of fecal incontinence in adults and rates the quality of evidence using the Grades of Recommendation, Assessment, Development, and Evaluation. Attention is given to type, strength, and application mode of the current for ES and to safety. METHODS Methods followed the Cochrane Handbook. Randomized controlled trials were included. Studies were searched in The Cochrane Library, MEDLINE, and EMBASE (registration number (PROSPERO): CRD42011001334). RESULTS BF and/or ES were studied in 13 randomized parallel-group trials. In 12 trials, at least one therapy group received BF alone and/or in combination with ES, while ES alone was evaluated in seven trials. Three (four) trials were rated as of high (moderate) quality. Average current strength was reported in three of seven studies investigating ES; only two studies reached the therapeutic window. No trial showed superiority of control, or of BF alone or of ES alone when compared with BF + ES. Superiority of BF + ES over any monotherapy was demonstrated in several trials. Amplitude-modulated medium-frequency (AM-MF) stimulation, also termed pre-modulated interferential stimulation, combined with BF was superior to both low-frequency ES and BF alone, and 50 % of the patients were continent after 6 months of treatment. Effects increased with treatment duration. Safety reporting was bad, and there are safety issues with some forms of low-frequency ES. CONCLUSIONS There is sufficient evidence for the efficacy of BF plus ES combined in treating fecal incontinence. AM-MF plus BF seems to be the most effective and safe treatment. KEY MESSAGES • The higher the quality of the randomized trial the more likely was a significant difference between treatment groups. • Two times more patients became continent when biofeedback was used instead of a control, such as pelvic floor exercises. • Two times more patients became continent when biofeedback plus electrical stimulation was used instead of biofeedback only. • Low-frequency electrical stimulation can have adverse device effects, and this is in contrast to amplitude-modulated medium-frequency electrical stimulation. • There is high quality evidence that amplitude-modulated medium-frequency electrical stimulation plus electromyography biofeedback is the best second-line treatment for fecal incontinence.
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Affiliation(s)
- Reinhard Vonthein
- Institut für Medizinische Biometrie und Statistik, Universität zu Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, Haus 24, 23562 Lübeck, Germany ,Zentrum für Klinische Studien Lübeck, Universität zu Lübeck, Lübeck, Germany
| | - Tankred Heimerl
- Klinik für Allgemein-, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Zentrum für minimalinvasive Chirurgie, Universitätsklinikum Gießen und Marburg GmbH, Standort Gießen, Gießen, Germany
| | - Thilo Schwandner
- Klinik für Allgemein-, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Zentrum für minimalinvasive Chirurgie, Universitätsklinikum Gießen und Marburg GmbH, Standort Gießen, Gießen, Germany
| | - Andreas Ziegler
- Institut für Medizinische Biometrie und Statistik, Universität zu Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, Haus 24, 23562 Lübeck, Germany ,Zentrum für Klinische Studien Lübeck, Universität zu Lübeck, Lübeck, Germany
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Norton C, Cody JD. Biofeedback and/or sphincter exercises for the treatment of faecal incontinence in adults. Cochrane Database Syst Rev 2012:CD002111. [PMID: 22786479 DOI: 10.1002/14651858.cd002111.pub3] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Christine Norton
- Bucks New University &Imperial College HealthcareNHS Trust, Uxbridge, UK.
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Ziegler A, Heimerl A, Krockenberger K, Hemmelmann C. [Utility of medical devices: approaches to planning and conducting clinical trials]. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2012; 106:322-31; discussion 332. [PMID: 22818149 DOI: 10.1016/j.zefq.2012.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Medicines and medical devices do not only differ in the approval process, but also in the aim and conduct of clinical trials. We first discuss important differences between medicinal products and medical devices. Emphasis is put on the differences in the framework for clinical trials. We point out that a different analysis set should be used in clinical trials of medical devices when compared with medicinal products and medical devices in the USA. Specifically, regulators generally ask for the full analysis set based on the intention-to-treat principle as proof of efficacy of medicines. A central aspect of clinical trials of medical devices is that they have to be tested under normal conditions of use according to the performance data. As a result, all data acquired while the medical device was not during normal conditions of use should be excluded from statistical analyses. We discuss statistical methodological particularities of medical devices, such as blinding and the control of placebo effects. Using the conservative treatment of anal incontinence as an example, we show that comprehensive technical and physical knowledge is required for assessing the utility of medical devices. Finally, we consider reporting of severe adverse events and of severe adverse device effects of medical devices.
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Affiliation(s)
- Andreas Ziegler
- Institut für Medizinische Biometrie und Statistik, Universität zu Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck.
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Biofeedback for the treatment of female pelvic floor muscle dysfunction: a systematic review and meta-analysis. Int Urogynecol J 2012; 23:1495-516. [PMID: 22426876 DOI: 10.1007/s00192-012-1707-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2011] [Accepted: 02/09/2012] [Indexed: 12/14/2022]
Abstract
Biofeedback (BF) has been widely used in the treatment of pelvic floor dysfunctions, mainly by promoting patient learning about muscle contraction with no side effects. However, its effectiveness remains poorly understood with some studies suggesting that BF offers no advantage over the isolated pelvic floor muscle training (PFMT). The main objective of this study was to systematically review available randomized controlled trials assessing the effectiveness of BF in female pelvic floor dysfunction treatment. Trials were electronically searched and rated for quality by use of the PEDro scale (values of 0-10). Randomized controlled trials assessing the training of pelvic floor muscle (PFM) using BF in women with PFM dysfunction were selected. Outcomes were converted to a scale ranging from 0 to 100. Trials were pooled with software used to prepare and update Cochrane reviews. Results are presented as weighted mean differences with 95 % confidence intervals (CI). Twenty-two trials with 1,469 patients that analyzed BF in the treatment of urinary, anorectal, and/or sexual dysfunctions were included. PFMT alone led to a superior but not significant difference in the function of PFM when compared to PFMT with BF, by using vaginal measurement in the short and intermediate term: 9.89 (95 % CI -5.05 to 24.83) and 15.03 (95 % CI -9.71 to 39.78), respectively. We found a few and nonhomogeneous studies addressing anorectal and sexual function, which do not provide the cure rate calculations. Limitations of this review are the low quality and heterogeneity of the studies, involving the usage of distinct protocols of interventions, and various and different outcome measures. The results of this systematic review suggest that PFMT with BF is not more effective than other conservative treatments for female PFM dysfunction.
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Lam TJ, Kuik DJ, Felt-Bersma RJF. Anorectal function evaluation and predictive factors for faecal incontinence in 600 patients. Colorectal Dis 2012; 14:214-23. [PMID: 21689265 DOI: 10.1111/j.1463-1318.2011.02548.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
AIM Anorectal function was assessed in patients with and without faecal incontinence (FI) . Risk factors predictive for FI were determined. METHOD Between 2003 and 2009, all consecutive patients referred were assessed by questionnaire, anorectal manometry and anal endosonography. Predictive factors were identified and used to develop a statistical model to predict FI. RESULTS Of 600 patients (519 women), 285 (48%) were faecally incontinent. In comparison with continent women, incontinent women (mean Vaizey score 15.4), were older, had more liquid stools, more deliveries, more urinary incontinence, lower anal pressures, shorter sphincter length, smaller rectal capacity and more sphincter defects. Incontinent men (mean Vaizey score 15.3) were older and had lower anal pressures. Incontinent and continent patients showed an overlap in test results. Predictors in women were age, stool consistency, anal pressures, rectal capacity, and internal and external sphincter defects. The area under the ROC-curve was 0.84 (P < 0.001; 95% confidence interval, 0.80-0.87). Using a cut off point of 0.4, FI was predicted with sensitivity, specificity, positive and negative predictive values of 86%, 68%, 74% and 82%, respectively. The model was studied in five women with a temporary stoma and was accurate in predicting FI after stoma closure. CONCLUSION Incontinent patients have lower pressures, smaller rectal capacity and more sphincter defects than controls, but show a large overlap. Our model shows a relatively high sensitivity and negative predictive value for predicting FI in women. The model seems promising in the patients studied with a temporary stoma.
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Affiliation(s)
- T J Lam
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, the Netherlands.
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Schwandner T, Hemmelmann C, Heimerl T, Kierer W, Kolbert G, Vonthein R, Weinel R, Hirschburger M, Ziegler A, Padberg W. Triple-target treatment versus low-frequency electrostimulation for anal incontinence: a randomized, controlled trial. DEUTSCHES ARZTEBLATT INTERNATIONAL 2011; 108:653-60. [PMID: 22013492 DOI: 10.3238/arztebl.2011.0653] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Accepted: 07/20/2011] [Indexed: 11/27/2022]
Abstract
BACKGROUND In the nonsurgical treatment of anal incontinence, the combination of amplitude-modulated medium-frequency stimulation and electromyographic biofeedback (EMG-BF), known as triple-target treatment (3T), is superior to EMG-BF alone. The aim of this trial is to compare 3T with the standard treatment, low-frequency stimulation (LFS). METHODS 80 patients with anal incontinence of Grade I or higher who presented to physicians or centers specialized in coloproctology were enrolled in this multicenter randomized trial with blinded observer. The trial had an open parallel-group design. Randomization was performed centrally by telephone. The primary endpoint was the Cleveland Clinic Score (CCS) after self-training at home with either 3T or LFS in two 20-minute sessions per day for 6 months. The secondary endpoints included the proportion of patients regaining continence, and the patients' quality of life (QoL). On completion of the trial as planned, the results were evaluated with an intention-to-treat analysis. STUDY REGISTRATION DRKS00000138 (http://register.germanctr.de). RESULTS 39 patients were randomized to 3T, and 41 to LFS. After 6 months of treatment, the CCS (mean ± standard deviation) was 3.1 ± 4.2 in the 3T group and 9.6 ± 3.9 in the LFS group. The median improvement in the CCS at 6 months compared to baseline was 7 points greater in the 3T group than in the LFS group (95% CI: 5-9, p<0.001). Anal continence was regained by 54% of the 3T patients, but none of the LFS patients (95% CI for the difference: 37.18% - 69.91%, p<0.001). QoL scores were higher in all dimensions in the 3T group than in the LFS group. No major adverse effects occurred in either group. CONCLUSION 3T is superior to LFS in the treatment of anal incontinence. The available evidence suggests that the success of 3T is based on the combined effect of biofeedback and medium-frequency stimulation. LFS of the type applied in this trial has no effect. 3T should be used in routine clinical practice instead of LFS.
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Affiliation(s)
- Thilo Schwandner
- Klinik für Allgemein-, Viszeral-, Thorax- und Transplantationschirurgie, Fachbereich Medizin, Justus-Liebig-Universität Giessen
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Becker H, Samel S. Alternative approaches to the treatment of fecal incontinence. DEUTSCHES ARZTEBLATT INTERNATIONAL 2011; 108:651-652. [PMID: 22013491 PMCID: PMC3196994 DOI: 10.3238/arztebl.2011.0651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Heinz Becker
- Klinik für Allgemein- und Viszeralchirurgie, Georg-August-Universität, Göttingen
| | - Stephan Samel
- Praxis für Koloproktologie und chirurgische Endoskopie, Göttingen
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Abstract
Defecatory disorders are a common cause of chronic constipation and should be managed by biofeedback-guided pelvic floor retraining. While anorectal tests are necessary to diagnose defecatory disorders, recent studies highlight the utility of a careful digital rectal examination. While obstetric anal injury can cause fecal incontinence (FI), diarrhea is a more important risk factor for FI among women in the community, who typically develop FI after age 40. Initial management of fecal incontinence should focus on bowel disturbances. Pelvic floor retraining with biofeedback therapy is beneficial for patients who do not respond to bowel management. Sacral nerve stimulation should be considered in patients who do not respond to conservative therapy.
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Affiliation(s)
- Adil E Bharucha
- Clinical and Enteric Neuroscience Translational and Epidemiological Research Program, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA.
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Savitt L, Thurler A. Biofeedback for Constipation and Fecal Incontinence. SEMINARS IN COLON AND RECTAL SURGERY 2011. [DOI: 10.1053/j.scrs.2010.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Gié O, Christoforidis D. Advances in the Treatment of Fecal Incontinence. SEMINARS IN COLON AND RECTAL SURGERY 2011. [DOI: 10.1053/j.scrs.2010.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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