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

Sexual functioning is not, but psychological burden is predictive for receiving help in pelvic physical therapy practice: A cross-sectional study

Background

Pelvic floor complaints are common among women and often accompanied by sexual dysfunction and psychological burden. They are also associated with pregnancy and childbirth. However, not all women with these complaints receive help in pelvic physical therapy practice. This study explored if pregnancy, parity, pelvic floor complaints, sexual functioning, and psychological burden are predictive of receiving help in pelvic physical therapy practice.

Methods

In a cross-sectional exploratory design, women completed an online survey about pelvic floor complaints, sexual function, and psychological burden. Binary logistic analysis was used to analyze the predictive value of the above-mentioned factors.

Results

Data from 542 participants were analyzed. Pregnancy and parity, PFC severity, psychological burden, and the interaction between pelvic floor complaints and psychological burden were significant predictors of receiving help. Against expectations, sexual functioning was not predictive of receiving help.

Conclusions

Women's psychological burden is an important factor in determining if or when women receive help in PPT practice. More research is needed to unravel the role of sexual functioning in the context of pelvic floor complaints and women's psychological burden. More insight into this area of expertise could possibly improve and enhance pelvic health care for women with pelvic floor complaints.

Restrictions and distress in daily, social, and sexual functioning, and intimate relationships in women with pelvic floor complaints: A mixed-method study

Women with pelvic floor complaints experience restrictions and distress in their daily, social, and sexual functioning, and their intimate relationships. We interviewed forty-eight women to unravel differences between women receiving and not receiving pelvic physical therapy and between pregnant, parous, and nulliparous women in preparation for theory development. We analyzed data in a mixed-method design using NVivo and Leximancer. Sexual dysfunction, relationship dynamics, the nature and severity of restrictions and distress, and coping strategies appear to vary between women receiving and not receiving therapy. Specific combinations of restrictions and distress are present in pregnant, parous, and nulliparous women, and might influence women's decision to seek help.

Centering Group Treatment for Women With Interstitial Cystitis/Bladder Pain Syndrome: A Qualitative Analysis

IMPORTANCE

Women with interstitial cystitis/bladder pain syndrome (ICBPS) face challenging treatment and feelings of isolation. Centering models of group medical visits have been successful in other spheres but have not been explored in ICBPS therapy.

OBJECTIVE

We sought to describe opinions of women with ICBPS regarding Centering visits, including advantages, experience, and barriers to participation and efficacy.

STUDY DESIGN

Patients who attended Centering visits participated in a focus group and/or filled out written commentary in evaluations, and control patients were individually interviewed. We coded transcripts using NVivo software for emergent themes.

RESULTS

We conducted 4 control patient individual interviews, had one focus group of Centering patients, and collected comments from 34 post-Centering surveys. Emergent themes of interest included motivations and barriers to joining, cost, leadership, connecting with others, diversity, learning, alternative treatments, and areas for improvement. Regardless of participation in Centering, patients noted the importance of self-care and sharing with other women with ICBPS, and they emphasized feelings of isolation in their disease and discouraging health care experiences. Women in Centering noted that the biggest advantages of Centering were learning from other women with ICBPS, the creation of a welcoming and safe space, and the feeling that Centering was more of a support group than a medical visit. Women noted that barriers to Centering included cost and logistical issues, such as time and format.

CONCLUSIONS

Women with ICBPS treatment note that Centering group visits provide a sense of learning and community that opens them to a wider variety of options.

Conceptualization and Inventory of the Sexual and Psychological Burden of Women With Pelvic Floor Complaints; A Mixed-Method Study

Introduction

Despite the fact that the literature reports various restrictions and types of distress in women with pelvic floor complaints, a comprehensive overview of women's sexual and psychological burden emerging from these complaints is lacking, which compromises our ability to assess and grasp the impact to women.

Aim

This study was performed to conceptualize women's sexual and psychological burden and create a more comprehensive overview on this topic from both women's and health care providers’ perspectives. Furthermore, this research intended to identify items to populate a to-be-developed instrument to assess sexual and psychological burden.

Methods

In Group Concept Mapping, 125 statements were used about restrictions and distress that women with pelvic floor complaints experienced. Women with, and health care providers with and without pelvic floor complaints (13 women and 3 men) sorted the statements into comprehensive self-labeled clusters and rated their nature and severity. Multidimensional scaling and hierarchical cluster analyses were performed to identify a conceptual model of coherent clusters of statements. Item-total correlations of severity scores were calculated to identify statements that can be used in future research to represent women's sexual and psychological burden.

Main Outcome Measure

A conceptual model emerged, and outcomes of item-total correlations were then examined again using the conceptual model.

Results

Seven distress clusters were identified, namely, loss of control, sexual distress, feeling insecure, feeling wronged, feeling helpless, feeling angry, and feeling disappointed. Feeling insecure appeared more pervasive than other distresses. Furthermore, 33 statements were identified that can be used in future research to develop an instrument to assess sexual and psychological burden representing both women's and health care providers’ perspectives.

Conclusion

The conceptual model and list of statements may concisely represent the sexual and psychological burden of women with pelvic floor complaints from both women's and health care providers’ perspectives on this topic.

Brand AM, Rosas S, Waterink W, et al. Conceptualization and Inventory of the Sexual and Psychological Burden of Women With Pelvic Floor Complaints; A Mixed-Method Study. Sex Med 2022;10:100504.

Guideline for the diagnosis and treatment of Faecal Incontinence-A UEG/ESCP/ESNM/ESPCG collaboration

INTRODUCTION

The goal of this project was to create an up-to-date joint European clinical practice guideline for the diagnosis and treatment of faecal incontinence (FI), using the best available evidence. These guidelines are intended to help guide all medical professionals treating adult patients with FI (e.g., general practitioners, surgeons, gastroenterologists, other healthcare workers) and any patients who are interested in information regarding the diagnosis and management of FI.

METHODS

These guidelines have been created in cooperation with members from the United European Gastroenterology (UEG), European Society of Coloproctology (ESCP), European Society of Neurogastroenterology and Motility (ESNM) and the European Society for Primary Care Gastroenterology (ESPCG). These members made up the guideline development group (GDG). Additionally, a patient advisory board (PAB) was created to reflect and comment on the draft guidelines from a patient perspective. Relevant review questions were established by the GDG along with a set of outcomes most important for decision making. A systematic literature search was performed using these review questions and outcomes as a framework. For each predefined review question, the study or studies with the highest level of study design were included. If evidence of a higher-level study design was available, no lower level of evidence was sought or included. Data from the studies were extracted by two reviewers for each predefined important outcome within each review question. Where possible, forest plots were created. After summarising the results for each review question, a systematic quality assessment using the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) approach was performed. For each review question, we assessed the quality of evidence for every predetermined important outcome. After evidence review and quality assessment were completed, recommendations could be formulated. The wording used for each recommendation was dependent on the level of quality of evidence. Lower levels of evidence resulted in weaker recommendations and higher levels of evidence resulted in stronger recommendations. Recommendations were discussed within the GDG to reach consensus.

RESULTS

These guidelines contain 45 recommendations on the classification, diagnosis and management of FI in adult patients.

CONCLUSION

These multidisciplinary European guidelines provide an up-to-date comprehensive evidence-based framework with recommendations on the diagnosis and management of adult patients who suffer from FI.

Prevalence and factors associated with pelvic floor dysfunction in university women: a cross-sectional study

Abstract Introduction Urinary incontinence (UI), fecal inconti-nence (FI), and genito-pelvic pain or penetration disorder (GPPPD) are considered pelvic floor dysfunction (PFD), and are mainly characterized by poor functionality of the pelvic floor muscles. Despite the relevance of these dysfunctions in women's lives, the demand for care is low. Objective To analyze the prevalence of PFD, in university women, and factors associated with PFD. Methods This is a cross-sectional study conducted at São Paulo State University, Marília, SP, Brazil, with undergraduate and/or postgraduate women aged over 18 years. An online questionnaire containing 40 open and multiple-choice questions about PFD was developed by the authors and a Google form was disclosed via social media (Facebook, Instagram) to the participants. The questionnaire was applied between April and July 2020. Results A sample of 707 participants was included. The average age was 22.5 ± 21.0 years old. The most prevalent PFD was GPPPD, reported by 30.7% of women, followed by UI (16.8%) and FI (3.2%). PFD was significant less reported in the Midwest region compared to other regions (p = 0.015) and significantly more prevalent in women who attended public university (p = 0.038), in women with UI, FI, and GPPPD. The association-test showed that attending public university showed association to UI (p < 0.001), FI (p = 0.008) and GPPPD (p = 0.006). In addition, parity showed association with GPPD (p = 0.032) and to attend health courses with UI (p = 0.002). Conclusion PFD is prevalent among university women and GPPPD was the most recurrent, followed by UI and FI. GPPPD was associated with parity and attending a public university. UI was associated with attending public university and health courses. FI was associated with attending a public university.

Accidental Bowel Leakage/Fecal Incontinence: Evidence-Based Management

Fecal incontinence is a highly prevalent and debilitating condition that negatively impacts quality of life. The etiology is often multifactorial and treatment can be hindered by lack of understanding of its mechanisms and available treatment options. This article reviews the evidence-based update for the management of fecal incontinence.

Traumatic deficient perineum: surgical management and outcome from a single center

INTRODUCTION AND HYPOTHESIS

Deficient perineum is a disruption of the perineal body and distal rectovaginal septum presenting with anal incontinence and a range of urogenital symptoms. There is scarce reported outcome of this condition with management often delayed and with a variety of surgical alternatives. This study aims to determine faecal continence outcomes after long-term surgical repair.

METHODS

Patients were included for analysis after surgical repair between 1989 and 2012. Cases were preoperatively assessed by endosonography and anorectal manometry with a record of their continence with the Cleveland Clinic Incontinence Score (CCIS). Surgical repair comprised an overlapping repair of the external anal sphincter (EAS) with levatorplasty. There was selective use of internal anal sphincter (IAS) suture and/or advancement perineoplasty for soft tissue reconstruction. Patients were clinically evaluated for functional outcomes with comparison of their postoperative CCIS.

RESULTS

There were 20 patients (median age 55.5 years; range 29-81 years) with a median duration of incontinence symptoms of 174 (range 1-540) months. All patients had an EAS and IAS defect with 14 (70%) undergoing an IAS suture and 10 (50%) a Corman-style anoplasty. Over a median follow-up of 137.2 (range 13-322) months, there was a significant decrease in the recorded median preoperative vs. postoperative CCIS 18, range 13-20 vs. 2, range 0-10, respectively; p < 0.001) with 18 (90%) satisfied with the functional outcome. Faecal diversion was not used in any of the patients.

CONCLUSIONS

Experienced delayed repair of a traumatic cloaca is associated with an acceptable functional outcome at medium- to long-term follow-up.

An epidemiology study of fecal incontinence in adult Chinese women living in urban areas

Background:

Fecal incontinence (FI) has been shown to be a common symptom in Western countries; however, there is few researches focusing on its epidemic condition in Chinese women. We conducted this national population-based epidemiology study to estimate the prevalence and risk factors of FI among adult Chinese women living in urban regions.

Methods:

This is a subgroup analysis of a national population-based epidemiology study of FI. Total 28,196 adult women from urban regions of six provinces and municipalities participated in this research from 2014 to 2015. They finished the questionnaire under the direction of trained interviewers. FI was defined as accidental leakage of flatus and/or liquid or solid stool at least once in the past. The FI prevalence trend and risk factors were identified by the Cochran-Armitage test, Chi-square test, and multivariable logistic regression.

Results:

The prevalence of FI in adult females in urban China was 0.43% (95% confidence interval: 0.35%–0.51%). Among women with FI, 42.96%, 82.96%, and 42.22% reported having leakage of solid, liquid stool, and gas, respectively. The overall FI prevalence and the incidence rate of solid stool/liquid stool/gas leakage increased with age. The mean Wexner score was 4.0% and 12.0% FI patients reported Wexner score ≥9. Body mass index ≥24 kg/m², pelvic organ prolapses, chronic constipation, chronic cough, alcohol consumption, physical diseases including chronic bronchitis and cancer, gynecological diseases like gynecological inflammation are risk factors for FI. Vaginal delivery was the risk factor for FI in females with labor history.

Conclusions:

FI was not a common symptom in adult Chinese women living in urban areas and there were some potential modifiable risk factors.

Trial Registration:

Chinses Clinical Trial Registry: ChiCTR-OCS-14004675; http://www.chictr.org.cn/showproj.aspx?proj=4898

Management of Fecal Incontinence

Nine percent of adult women experience episodes of fecal incontinence at least monthly. Fecal incontinence is more common in older women and those with chronic bowel disturbance, diabetes, obesity, prior anal sphincter injury, or urinary incontinence. Fecal incontinence negatively affects quality of life and mental health and is associated with increased risk of nursing home placement. Fewer than 30% of women with fecal incontinence seek care, and lack of information about effective solutions is an important barrier for both patients and health care professionals. Even among women with both urinary and fecal incontinence presenting for urogynecologic care, the rate of verbal disclosure of fecal incontinence symptoms remains low. This article provides an overview of the evaluation and management of fecal incontinence for the busy obstetrician-gynecologist, incorporating existing guidance from the American College of Obstetricians and Gynecologists, the American College of Gastroenterology, and the American Society of Colon and Rectal Surgeons. The initial clinical evaluation of fecal incontinence requires a focused history and physical examination. Recording patient symptoms using a standard diary or questionnaire can help document symptoms and response to treatment. Invasive diagnostic testing and imaging generally are not needed to initiate treatment but may be considered in complex cases. Most women have mild symptoms that will improve with optimized stool consistency and medications. Additional treatment options include pelvic floor muscle strengthening with or without biofeedback, devices placed anally or vaginally, and surgery, including sacral neurostimulation, anal sphincteroplasty, and, for severely affected individuals for whom other interventions fail, colonic diversion.

ACOG Practice Bulletin No. 210: Fecal Incontinence

Fecal incontinence, or the involuntary leakage of solid or loose stool, is estimated to affect 7-15% of community-dwelling women (1). It is associated with reduced quality of life, negative psychologic effects, and social stigma (2), yet many women do not report their symptoms or seek treatment. Less than 3% of women who do self-report fecal incontinence will have this diagnosis recorded in their medical record (3). Obstetrician-gynecologists are in a unique position to identify women with fecal incontinence because pregnancy, childbirth, obstetric anal sphincter injuries (OASIS), and pelvic floor dysfunction are important risk factors that contribute to fecal incontinence in women. The purpose of this Practice Bulletin is to provide evidence-based guidelines on the screening, evaluation, and management of fecal incontinence to help obstetrician-gynecologists diagnose the condition and provide conservative treatment or referral for further work up and surgical management when appropriate. For discussion on fecal incontinence associated with OASIS, see Practice Bulletin No. 198, Prevention and Management of Obstetric Lacerations at Vaginal Delivery (4).

Pelvic floor dysfunction in the immediate puerperium, and 1 and 3 months after vaginal or cesarean delivery

OBJECTIVE

To identify and assess postpartum pelvic floor dysfunction (PFD) between vaginal delivery, elective cesarean delivery (ECD), and intrapartum cesarean delivery (ICD).

METHODS

The present prospective observational study included women aged at least 18 years with no history of pelvic surgery or lower urinary tract malformation, and who had not undergone pelvic floor muscle (PFM) training in the preceding 12 months, who underwent delivery at Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil between August 1, 2016, and May 31, 2017. Participants were assessed at 48 hours (phase 1), 1 month (phase 2), and 3 months (phase 3) after delivery. Assessments included the International Consultation on Incontinence Questionnaire, Short Form (ICIQ-SF); the Jorge-Wexner anal incontinence scale; a self-rated visual analog scale for pelvic pain; the pelvic organ prolapse quantification (POP-Q) system; and a PFM perineometer.

RESULTS

A total of 227 women were assessed in phase 1 (141 vaginal deliveries; 28 ICDs; and 58 ECDs), 79 in phase 2, and 41 in phase 3. The ICIQ-SF, Jorge-Wexner scale, visual analog scale, and perineometer measurements did not identify significant differences in relation to the type of delivery (P>0.05).

CONCLUSION

The type of delivery was not associated with differences in the short-term development of postpartum PFD.

Prevalence of and Factors Associated With Fecal Incontinence: Results From a Population-Based Survey

BACKGROUND & AIMS

Fecal incontinence (FI) is characterized by uncontrolled passage of solid or liquid stool. We aimed to determine the prevalence and severity of FI in a large sample of US residents.

METHODS

We recruited a representative sample of patients in October 2015 to complete the National Gastrointestinal (GI) Survey; a mobile app called MyGiHealth was used to systematically collect data on GI symptoms. FI was defined as accidental leakage of solid or liquid stool. Severity of FI was determined by responses to the National Institutes of Health FI Patient Reported Outcomes Measurement Information System questionnaire. Multivariable regression models were used to identify factors associated with FI prevalence and severity.

RESULTS

Among 71,812 individuals who completed the National GI Survey, 14.4% reported FI in the past; of these, 33.3% had FI within the past 7 days. Older age, male sex, and Hispanic ethnicity increased the likelihood of having FI within the past week. Individuals with Crohn's disease, ulcerative colitis, celiac disease, irritable bowel syndrome, or diabetes were more likely to report FI. Non-Hispanic black and Hispanic individuals and individuals with Crohn's disease, celiac disease, diabetes, human immunodeficiency virus/acquired immunodeficiency syndrome, or chronic idiopathic constipation had more severe symptoms of FI than individuals without these features.

CONCLUSIONS

In a large population-based survey, 1 in 7 people reported previous FI. FI is age-related and more prevalent among individuals with inflammatory bowel disease, celiac disease, irritable bowel syndrome, or diabetes than people without these disorders. Proactive screening for FI among these groups is warranted.

Prevalence of anal incontinence in a working population within a healthcare environment

OBJECTIVES

Anal incontinence is a devastating affliction with several considerations that make it difficult to define in terms of epidemiology with good precision. The aim of the present work is to study the prevalence of an important disorder such as anal incontinence in a healthy working population within a sanitary environment.

MATERIAL AND METHODS

A cluster of easy understanding and filling inquiry forms are distributed to 910 apparently healthy individuals at our hospital. This questionnaires include filiation data, passed medical history, presence or not of Incontinence and other symptoms such as urgency. The Cleveland Clinic Incontinence Score is also registered.

RESULTS

Anal incontinence is present in a 21.2% of subjects when considered in any of it forms (flatus, liquid or solid faeces). A Clevleand Clinic Incontinence Score higher than 6 was obtained in a 7.3% of the sample and higher than 10 in 1.2%. No gender predominance has been identified. A slightly higher severity is recognised with increasing age. Obstetric and anal surgical background are the only related factors identified in the studied sample.

CONCLUSIONS

Faecal incontinence is a high prevalent affliction, even among apparently healthy population. Considering the aetiologic factors that have been established, prevention during obstetric and anal surgical procedures is absolutely mandatory.

Barriers to seeking care for accidental bowel leakage: a qualitative study

INTRODUCTION AND HYPOTHESIS

Fewer than 50 % of women with urinary incontinence (UI) and 30 % of women with accidental bowel leakage (ABL) seek care. We sought to describe barriers to care seeking for ABL to inform development of an instrument to measure these barriers.

METHODS

We recruited women with ABL with varied prior care-seeking experiences to participate in focus groups and cognitive interviews so we could understand factors that may have prevented or delayed care seeking. Focus groups continued until thematic saturation was reached using conventional content analysis. Final themes were established and characterized by comparing within and across the focus groups and with previously described UI and ABL care-seeking barriers. Cognitive interviews were confirmatory.

RESULTS

Thirty-nine women (aged 46-85) participated in six focus groups and ten cognitive interviews; 89 % were white, 8 % African American, and 3 % Latina. We identified 12 barriers to seeking care for ABL: (1) Lack of knowledge about the condition; (2) Lack of knowledge about treatment; (3) Fear of testing/treatment; (4) Normative thinking; (5) Avoidance/denial; (6) Life impact; (7) Embarrassment/shame; (8) Self-blame; (9) Stigma; (10) Isolation; (11) Provider barriers; (12) Access limitations. These 12 barriers encompassed three overarching themes: the internalized self in relation to ABL; perceptions about ABL and its treatments; and interaction with the healthcare system.

CONCLUSIONS

ABL care-seeking barriers are similar to those described for UI, with the notable addition of lack of knowledge that ABL is a medical condition experienced by others. Interventions to promote access to effective treatments for ABL should include information about prevalence and treatability.

Fecal Incontinence: Epidemiology, Impact, and Treatment

Fecal incontinence (FI) is a chronic and debilitating condition that carries a significant health, economic, and social burden. FI has a considerable psychosocial and financial impact on patients and their families. A variety of treatment modalities are available for FI including behavioral and dietary modifications, pharmacotherapy, pelvic floor physical therapy, bulking agents, anal sphincteroplasty, sacral nerve stimulation, artificial sphincters, magnetic sphincters, posterior anal sling, and colostomy.

Living with constipation--older people's experiences and strategies with constipation before and during hospitalization

BACKGROUND

Constipation is a common problem among older people. This study aimed to explore how older patients experience constipation and which strategies they used in handling the condition before and during hospitalization.

METHODS

A qualitative exploratory research design was used. Fourteen semi-structured interviews were conducted with patients (61-91 years of age) during hospitalization. Data were analyzed by using content analysis.

RESULTS

Themes concerning experiences were Bodily signs and symptoms of constipation; the participants described severe pain during constipation, as well as pronounced relief after bowel movements, Impact on well-being and social activities; being constipated negatively impacted their mood and limited social activities, Striving for bowel balance; the participants experienced an ongoing strive for balancing between constipation and diarrhea. Themes related to strategies were Struggling to find a solution; they were aware of different strategies to prevent and treat constipation, though the most common solution described was the use of laxatives, Wait and see; the participants were awaiting to take action until they experienced constipation symptoms, Constipation is a private problem being challenged during hospitalization; constipation was considered a private issue rarely discussed with health-care professionals.

CONCLUSION

This study illuminates the need for health-care professionals to be attentive to this issue and initiate the conversation with patients in order to advise on the management of constipation.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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