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Luo C, Wei D, Pang K, Mei L, Chen Y, Niu X. Is percutaneous tibial nerve stimulation (PTNS) effective for fecal incontinence (FI) in adults compared with sham electrical stimulation? A meta-analysis. Tech Coloproctol 2024; 28:37. [PMID: 38401006 DOI: 10.1007/s10151-024-02910-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 01/27/2024] [Indexed: 02/26/2024]
Abstract
BACKGROUND Sacral nerve neuromodulation (SNM) has been considered the optimal second-line treatment for fecal incontinence (FI). However, SNM involves high cost and requires highly skilled operators. Percutaneous tibial nerve stimulation (PTNS) has emerged as an alternative treatment modality for FI, yielding varying clinical outcomes. We conducted this meta-analysis to evaluate the effectiveness and safety of PTNS compared to sham electrical stimulation for FI. METHODS PubMed, Embase, Web of Science, and the Cochrane Library were searched for studies from May 12, 2012 to May 12, 2022. RESULTS Four randomized controlled studies were included in this review, involving a total of 439 adult patients with FI (300 in the PTNS group and 194 in the sham electrical stimulation group). Our meta-analysis revealed that PTNS demonstrated superior efficacy in reducing weekly episodes of FI compared to the control groups (MD - 1.6, 95% CI - 2.94 to - 0.26, p = 0.02, I2 = 30%). Furthermore, a greater proportion of patients in the PTNS group reported more than a 50% reduction in FI episodes per week (RR 0.73, 95% CI 0.57-0.94, p = 0.02, I2 = 6%). However, no significant differences were observed in any domains of the FI Quality of Life (QoL) and St Mark's incontinence scores (MD - 2.41, 95% CI - 5.1 to 0.27, p = 0.08, I2 = 67%). Importantly, no severe adverse events related to PTNS were reported in any of the participants. CONCLUSIONS Our meta-analysis revealed that PTNS was more effective than sham stimulation in reducing FI episodes and led to a higher proportion of patients reporting more than a 50% reduction in weekly FI episodes.
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Affiliation(s)
- Can Luo
- Department of Gynecology and Obstetrics, West China Second Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Dongmei Wei
- Department of Gynecology and Obstetrics, West China Second Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Kaiyin Pang
- Department of Gynecology and Obstetrics, West China Second Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Ling Mei
- Department of Gynecology and Obstetrics, West China Second Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Yueyue Chen
- Department of Gynecology and Obstetrics, West China Second Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Xiaoyu Niu
- Department of Gynecology and Obstetrics, West China Second Hospital, Sichuan University, Chengdu, China.
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China.
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Assmann SL, Keszthelyi D, Kleijnen J, Anastasiou F, Bradshaw E, Brannigan AE, Carrington EV, Chiarioni G, Ebben LDA, Gladman MA, Maeda Y, Melenhorst J, Milito G, Muris JWM, Orhalmi J, Pohl D, Tillotson Y, Rydningen M, Svagzdys S, Vaizey CJ, Breukink SO. Guideline for the diagnosis and treatment of Faecal Incontinence-A UEG/ESCP/ESNM/ESPCG collaboration. United European Gastroenterol J 2022; 10:251-286. [PMID: 35303758 PMCID: PMC9004250 DOI: 10.1002/ueg2.12213] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 02/02/2022] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Sadé L. Assmann
- Department of Surgery and Colorectal SurgeryMaastricht University Medical CentreMaastrichtThe Netherlands
- Division of Gastroenterology‐HepatologyDepartment of Internal MedicineMaastricht University Medical CentreMaastrichtThe Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM)Maastricht UniversityMaastrichtThe Netherlands
| | - Daniel Keszthelyi
- Division of Gastroenterology‐HepatologyDepartment of Internal MedicineMaastricht University Medical CentreMaastrichtThe Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM)Maastricht UniversityMaastrichtThe Netherlands
| | - Jos Kleijnen
- School for Oncology and Developmental Biology (GROW)Maastricht UniversityMaastrichtThe Netherlands
| | - Foteini Anastasiou
- 4rth TOMY – Academic Primary Care Unit Clinic of Social and Family MedicineUniversity of CreteHeraklionGreece
| | - Elissa Bradshaw
- Community Gastroenterology Specialist NurseRoyal Free HospitalLondonEnglandUK
| | | | - Emma V. Carrington
- Surgical Professorial UnitDepartment of Colorectal SurgerySt Vincent's University HospitalDublinIreland
| | - Giuseppe Chiarioni
- Division of Gastroenterology of the University of VeronaAOUI VeronaVeronaItaly
- Center for Functional GI and Motility DisordersUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | | | - Marc A. Gladman
- The University of AdelaideAdelaide Medical SchoolFaculty of Health & Medical SciencesAdelaideAustralia
| | - Yasuko Maeda
- Department of Surgery and Colorectal SurgeryWestern General HospitalEdinburghUK
| | - Jarno Melenhorst
- Department of Surgery and Colorectal SurgeryMaastricht University Medical CentreMaastrichtThe Netherlands
- School for Oncology and Developmental Biology (GROW)Maastricht UniversityMaastrichtThe Netherlands
| | | | - Jean W. M. Muris
- Department of General PracticeCare and Public Health Research InstituteMaastricht UniversityMaastrichtThe Netherlands
| | | | - Daniel Pohl
- Department of Gastroenterology and HepatologyUniversity Hospital ZurichZurichSwitzerland
- Department of Gastrointestinal SurgeryUniversity Hospital of North NorwayTromsøNorway
| | | | - Mona Rydningen
- Norwegian National Advisory Unit on Incontinence and Pelvic Floor HealthTromsøNorway
| | - Saulius Svagzdys
- Medical AcademyLithuanian University of Health SciencesClinic of Surgery Hospital of Lithuanian University of Health Sciences Kauno KlinikosKaunasLithuania
| | | | - Stephanie O. Breukink
- Department of Surgery and Colorectal SurgeryMaastricht University Medical CentreMaastrichtThe Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM)Maastricht UniversityMaastrichtThe Netherlands
- School for Oncology and Developmental Biology (GROW)Maastricht UniversityMaastrichtThe Netherlands
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3
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Rodríguez Carrillo R, Ruiz Carmona MD, Alós Company R, Frangi Caregnato A, Alarcón Iranzo M, Solana Bueno A, Lozoya Trujillo R, García-Granero Ximénez E. Importance of some technical aspects of the procedure of percutaneous posterior tibial nerve stimulation in patients with fecal incontinence. Cir Esp 2021; 99:585-592. [PMID: 34373228 DOI: 10.1016/j.cireng.2021.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 08/25/2020] [Indexed: 11/18/2022]
Abstract
INTRODUCTION The results of percutaneous posterior tibial nerve stimulation (PTNS) in the treatment of fecal incontinence (IF) are modest. The aim of the study is to assess the relationship of some technical aspects with the clinical response: location of the nerve, distal response (motor or sensory) and accommodation. METHODS Prospective study of patients with FI undergoing PTNS therapy. The clinical response was assessed using the Wexner scale, defecation diary and anorectal manometry. RESULTS 32 patients were studied. The intensity of localization (proximity to the nerve) was not correlated with clinical or manometric changes. Motor response was associated with a decrease on the Wexner scale [12.12 (±5.39) to 7.71 (±4.57) P < .005], the number of episodes of passive incontinence [8.78 (±9.64) to 4.11 (±7.11) P = .025], the total number of incontinence episodes [16.11 (±16.03) to 7.78 (±11.34) P = .009] and the number of days with fecal soiling [6.89 (±5.53) to 2.56 (±4.13) P = .002] and with an increase in the length of the manometric anal canal at rest [4.55 (±0.596) to 4.95 (±0.213) P = .004]. The increase in stimulation (accommodation) was inversely correlated with the decrease in the Wexner scale (r = -0.677 P < .005) and the number of days with soiling (r = -0.650 P = .022). CONCLUSIONS The motor response during PTNS seems to be related to a better clinical response. The accommodation phenomenon could be associated with worse results. The proximity of the electrode to the nerve does not seem to be important as long as a good distal response is achieved.
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Affiliation(s)
| | | | - Rafael Alós Company
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | | | - Marina Alarcón Iranzo
- Servicio de Cirugía General y del Aparato Digestivo, Hospital de Sagunto, Valencia, Spain
| | - Amparo Solana Bueno
- Servicio de Cirugía General y del Aparato Digestivo, Hospital de Sagunto, Valencia, Spain
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4
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Meurette G, Siproudhis L, Leroi AM, Damon H, Urs Josef Keller D, Faucheron JL. Sacral neuromodulation with the InterStim™ system for faecal incontinence: results from a prospective French multicentre observational study. Colorectal Dis 2021; 23:1463-1473. [PMID: 33387373 DOI: 10.1111/codi.15507] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/06/2020] [Accepted: 11/23/2020] [Indexed: 12/26/2022]
Abstract
AIM The aim of this work was to evaluate the effectiveness, patient satisfaction and quality of life (QoL) and the safety of sacral neuromodulation (SNM) with the InterStimTM system for the treatment of faecal incontinence (FI) and establish whether results published predominantly by expert sites are generalisable. METHOD This is a prospective, multicentre, observational study that invited all French sites treating FI with the InterStim™ system to enrol subjects indicated for an SNM therapy evaluation. Data were collected at three follow-up visits within 1 and 15 months. Therapeutic effectiveness was evaluated by the reduction in leakages per week and improvements over time in the ability to defer defaecation and QoL (as measured with the Faecal Incontinence Quality of Life score). Safety was assessed through reported adverse events. RESULTS A total of 221 subjects with a mean age of 62.1 years were tested (184 women) and 178 received a permanent implant. For all implanted subjects with diary data at baseline and follow-up, a reduction in leakage of more than 50% was observed in 80%, 76% and 83% at 1-3, 4-8 and 9-15 months, respectively. The mean number of leakage episodes and urgency improved significantly compared with the baseline (p < 0.0001). Subjects showed improvements in QoL and time to defer defaecation and were generally satisfied with their therapy. The main device-related adverse event was the requirement to undertake reprogramming (in 52% of subjects with actions following an event). The rates of infection (in 6% of subjects) and surgical revision (in 10% of subjects) were in agreement with literature reports. CONCLUSION This study confirms the clinical effectiveness, safety and positive effect of SNM on QoL as well as high patient satisfaction for the treatment of FI in real-life.
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Affiliation(s)
| | | | | | - Henri Damon
- Hôpital Edouard Herriot, CHU de Lyon, Lyon, France
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5
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Rodríguez Carrillo R, Ruiz Carmona MD, Alós Company R, Frangi Caregnato A, Alarcón Iranzo M, Solana Bueno A, Lozoya Trujillo R, García-Granero Ximénez E. Importance of some technical aspects of the procedure of percutaneous posterior tibial nerve stimulation in patients with fecal incontinence. Cir Esp 2020; 99:S0009-739X(20)30276-1. [PMID: 32981656 DOI: 10.1016/j.ciresp.2020.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 08/24/2020] [Accepted: 08/25/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The results of percutaneous posterior tibial nerve stimulation (PTNS) in the treatment of fecal incontinence (IF) are modest. The aim of the study is to assess the relationship of some technical aspects with the clinical response: location of the nerve, distal response (motor or sensory) and accommodation. METHODS Prospective study of patients with FI undergoing PTNS therapy. The clinical response was assessed using the Wexner scale, defecation diary and anorectal manometry. RESULTS 32 patients were studied. The intensity of localization (proximity to the nerve) was not correlated with clinical or manometric changes. Motor response was associated with a decrease on the Wexner scale [12.12 (± 5.39) to 7.71 (± 4.57) p < 0.005], the number of episodes of passive incontinence [8.78 (± 9.64) to 4.11 (± 7.11) p = 0.025], the total number of incontinence episodes [16.11 (± 16.03) to 7.78 (± 11.34) p = 0.009] and the number of days with faecal soiling [6.89 (± 5.53) to 2.56 (± 4.13) p = 0.002] and with an increase in the length of the manometric anal canal at rest [4.55 (± 0.596) to 4.95 (± 0.213) p = 0.004]. The increase in stimulation (accommodation) was inversely correlated with the decrease in the Wexner scale (r = -0.677 p < 0.005) and the number of days with soiling (r = -0.650 p = 0.022). CONCLUSIONS The motor response during PTNS seems to be related to a better clinical response. The accommodation phenomenon could be associated with worse results. The proximity of the electrode to the nerve does not seem to be important as long as a good distal response is achieved.
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Affiliation(s)
| | | | - Rafael Alós Company
- Servicio de Cirugía General y del Aparato Digestivo. Hospital Universitario y Politécnico La Fe, Valencia, España
| | | | - Marina Alarcón Iranzo
- Servicio de Cirugía General y del Aparato Digestivo. Hospital de Sagunto, Valencia, España
| | - Amparo Solana Bueno
- Servicio de Cirugía General y del Aparato Digestivo. Hospital de Sagunto, Valencia, España
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6
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Rodríguez Carrillo R, Ruiz Carmona MD, Alós Company R, Frangi Caregnato A, Alarcón Iranzo M, Solana Bueno A, Lozoya Trujillo R, García-Granero Ximénez E. Evaluation of the anorectal motor response after percutaneous stimulation of the posterior tibial nerve in patients with fecal incontinence. Tech Coloproctol 2019; 23:987-992. [PMID: 31538295 DOI: 10.1007/s10151-019-02092-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 09/12/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND The effect of posterior tibial nerve stimulation (PTNS) on the mechanisms of anal continence has not been fully demonstrated. The aim of this study was to assess the anal manometric response after percutaneous PTNS in patients with fecal incontinence (FI). METHODS This was a prospective study in patients with FI undergoing 1 weekly session of percutaneous PTNS for 8 weeks. A clinical assessment (Wexner scale) and a complete study of up to 22 manometric parameters were carried out prior to treatment and 2-4 weeks after the end of treatment. RESULTS A total of 32 patients were evaluated. After therapy, there was a decrease in the average Wexner score [12.6 (± 5.2) to 9.5 (± 5.2) (P < 0.005)] and an increase in the "anal canal length at rest" [4.55 (± 0.60) to 4.95 (± 0.21) P = 0.004], without observing variations in other manometric parameters. The decrease in the Wexner score was significantly correlated with an increase in the "pressure at 5 cm at rest" after therapy (r = 0.464 P = 0.030). CONCLUSIONS In our study, PTNS was associated with a significant decrease in the Wexner score and with an increase in the functional length of the anal canal at rest. The improvement in the Wexner scale was correlated with an increase in pressure at rest in the theoretical area of the anorectal junction.
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Affiliation(s)
- R Rodríguez Carrillo
- Servicio de Cirugía General y del Aparato Digestivo, Hospital de Sagunto, Valencia, Spain.
| | - M D Ruiz Carmona
- Servicio de Cirugía General y del Aparato Digestivo, Hospital de Sagunto, Valencia, Spain
| | - R Alós Company
- Servicio de Cirugía General y del Aparato Digestivo, Hospital de Sagunto, Valencia, Spain
| | - A Frangi Caregnato
- Servicio de Cirugía General y del Aparato Digestivo, Hospital de Sagunto, Valencia, Spain
| | - M Alarcón Iranzo
- Servicio de Cirugía General y del Aparato Digestivo, Hospital de Sagunto, Valencia, Spain
| | - A Solana Bueno
- Servicio de Cirugía General y del Aparato Digestivo, Hospital de Sagunto, Valencia, Spain
| | - R Lozoya Trujillo
- Servicio de Cirugía General y del Aparato Digestivo, Hospital de Sagunto, Valencia, Spain
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7
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Hounsome N, Roukas C. Cost-effectiveness of sacral nerve stimulation and percutaneous tibial nerve stimulation for faecal incontinence. Therap Adv Gastroenterol 2018; 11:1756284818802562. [PMID: 30305847 PMCID: PMC6176537 DOI: 10.1177/1756284818802562] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 08/23/2018] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Subcutaneous sacral nerve stimulation is recommended by the United Kingdom (UK) National Institute for Health and Care Excellence (NICE) as a second-line treatment for patients with faecal incontinence who failed conservative therapy. Sacral nerve stimulation is an invasive procedure associated with complications and reoperations. This study aimed to investigate whether delivering less invasive and less costly percutaneous tibial nerve stimulation prior to sacral nerve stimulation is cost-effective. METHODS A decision analytic model was developed to estimate the cost-effectiveness of percutaneous tibial nerve stimulation with subsequent subcutaneous sacral nerve stimulation versus subcutaneous sacral nerve stimulation alone. The model was populated with effectiveness data from systematic reviews and cost data from randomized studies comparing both procedures in a UK National Health Service (NHS) setting. RESULTS Offering percutaneous tibial nerve stimulation prior to sacral nerve stimulation (compared with delivering sacral nerve stimulation straight away) was both more effective and less costly in all modeled scenarios. The estimated savings from offering percutaneous tibial nerve stimulation first were £662-£5,697 per patient. The probability of this strategy being cost-effective was around 80% at £20,000-£30,000 per quality-adjusted life-year (QALY). CONCLUSION Our analyses suggest that offering patients percutaneous tibial nerve stimulation prior to sacral nerve stimulation can be both cost-effective and cost-saving in the treatment of faecal incontinence.
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Affiliation(s)
| | - Chris Roukas
- Pragmatic Clinical Trials Unit, Queen Mary
University of London, London, UK
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8
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Sanagapalli S, Harrington S, Zarate-Lopez N, Emmanuel A. Posterior Tibial Nerve Stimulation for the Treatment of Fecal Incontinence Following Obstetric Anal Sphincter Injury. Neuromodulation 2018; 21:688-693. [DOI: 10.1111/ner.12844] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 05/08/2018] [Accepted: 06/04/2018] [Indexed: 12/12/2022]
Affiliation(s)
- Santosh Sanagapalli
- GI Physiology Unit; University College London Hospital; London UK
- Department of Gastroenterology; St Vincent's Hospital Sydney; Darlinghurst NSW Australia
- St Vincent's Clinical School; University of New South Wales; Sydney NSW Australia
| | | | | | - Anton Emmanuel
- GI Physiology Unit; University College London Hospital; London UK
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9
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Heywood NA, Pearson JS, Nicholson JE, Molyneux C, Sharma A, Kiff ES, Whorwell PJ, Telford KJ. The short-term effects of posterior tibial nerve stimulation on anorectal physiology in patients with faecal incontinence: a single centre experience. Therap Adv Gastroenterol 2018; 11:1756284818786111. [PMID: 30034533 PMCID: PMC6048664 DOI: 10.1177/1756284818786111] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 06/06/2018] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Posterior tibial nerve stimulation (PTNS) is a novel treatment for patients with faecal incontinence (FI) and may be effective in selected patients; however, its mechanism of action is unknown. We sought to determine the effects of PTNS on anorectal physiological parameters. METHODS Fifty patients with FI underwent 30 min of PTNS treatment, weekly for 12 weeks. High-resolution anorectal manometry, bowel diaries and Vaizey questionnaires were performed before and after treatment. Successful treatment was determined as a greater than 50% reduction in FI episodes. RESULTS Fifty patients with FI were studied; 39 women, median age 62 years (range 30-82). Compared with pretreatment, there were reductions in episodes of urgency (16.0 versus 11.4, p = 0.006), overall FI (14.5 versus 9.1, p = 0.001), urge FI (5.4 versus 3.2, p = 0.016) and passive FI (9.1 versus 5.9, p = 0.008). Vaizey score was reduced (16.1 versus 14.5, p = 0.002). Rectal sensory volumes (ml) decreased (onset 40.3 versus 32.6, p = 0.014, call 75.7 versus 57.5, p < 0.001, urge 104.1 versus 87.4, p = 0.004). There was no significant change in anal canal pressures (mmHg) (maximum resting pressure 41.4 versus 44.2, p = 0.39, maximum squeeze pressure, 78.7 versus 88.2, p = 0.15, incremental squeeze pressure 37.2 versus 44.1, p = 0.22). Reduction in FI episodes did not correlate with changes in physiological parameters (p > 0.05). Treatment success of 44% was independent of changes in manometric parameters (p > 0.05). CONCLUSIONS PTNS has a measureable physiological effect on rectal sensory volumes without an effect on anal canal pressures. It also reduces FI episodes; however, this effect is independent of changing physiology, suggesting that PTNS has a complex mechanism of action.
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Affiliation(s)
| | | | | | | | | | | | - Peter J. Whorwell
- University Hospital of South Manchester &
Manchester University, Manchester, UK
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10
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Simillis C, Lal N, Qiu S, Kontovounisios C, Rasheed S, Tan E, Tekkis PP. Sacral nerve stimulation versus percutaneous tibial nerve stimulation for faecal incontinence: a systematic review and meta-analysis. Int J Colorectal Dis 2018; 33:645-648. [PMID: 29470730 DOI: 10.1007/s00384-018-2976-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/07/2018] [Indexed: 02/04/2023]
Abstract
AIMS Percutaneous tibial nerve stimulation (PTNS) and sacral nerve stimulation (SNS) are both second-line treatments for faecal incontinence (FI). To compare the clinical outcomes and effectiveness of SNS versus PTNS for treating FI in adults. METHOD A literature search of MEDLINE, Embase, Science Citation Index Expanded and Cochrane was performed in order to identify studies comparing SNS and PTNS for treating FI. A risk of bias assessment was performed using The Cochrane Collaboration's risk of bias tool. A random effects model was used for the meta-analysis. RESULTS Four studies (one randomised controlled trial and three nonrandomised prospective studies) reported on 302 patients: 109 underwent SNS and 193 underwent PTNS. All included studies noted an improvement in symptoms after treatment, without any significant difference in efficacy between SNS and PTNS. Meta-analysis demonstrated that the Wexner score improved significantly with SNS compared to PTNS (weighted mean difference 2.27; 95% confidence interval 3.42, 1.12; P < 0.01). Moreover, SNS was also associated with a significant reduction in FI episodes per week and a greater improvement in the Fecal Incontinence Quality of Life coping and depression domains, compared to PTNS on short-term follow-up. Only two studies reported on adverse events, reporting no serious adverse events with neither SNS nor PTNS. CONCLUSION Current evidence suggests that SNS results in significantly improved functional outcomes and quality of life compared to PTNS. No serious adverse events were identified with either treatment. Further, high-quality, multi-centre randomised controlled trials with standardised outcome measures and long-term follow-up are required in this field.
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Affiliation(s)
- Constantinos Simillis
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, Fulham Road, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK.,Department of Colorectal Surgery, Royal Marsden Hospital, Fulham Road, London, UK
| | - Nikhil Lal
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, Fulham Road, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - Shengyang Qiu
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, Fulham Road, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - Christos Kontovounisios
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, Fulham Road, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - Shahnawaz Rasheed
- Department of Surgery and Cancer, Imperial College, London, UK.,Department of Colorectal Surgery, Royal Marsden Hospital, Fulham Road, London, UK
| | - Emile Tan
- Department of Colorectal Surgery, Singapore General Hospital, Academia, 20 College Road, Singapore, 169856, Singapore.
| | - Paris P Tekkis
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, Fulham Road, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK.,Department of Colorectal Surgery, Royal Marsden Hospital, Fulham Road, London, UK
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11
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Sanagapalli S, Neilan L, Lo JYT, Anandan L, Liwanag J, Raeburn A, Athanasakos E, Zarate-Lopez N, Emmanuel A. Efficacy of Percutaneous Posterior Tibial Nerve Stimulation for the Management of Fecal Incontinence in Multiple Sclerosis: A Pilot Study. Neuromodulation 2018; 21:682-687. [PMID: 29575432 DOI: 10.1111/ner.12764] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 12/09/2017] [Accepted: 01/04/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Fecal incontinence is a debilitating and highly prevalent problem among multiple sclerosis patients. Conservative therapies often fail to provide benefit. Posterior tibial nerve stimulation is a minimally invasive neuromodulatory therapy with proven efficacy for fecal incontinence in non-neurological settings. OBJECTIVE To evaluate the efficacy of posterior tibial nerve stimulation in treating multiple sclerosis-related fecal incontinence. METHODS Consecutive multiple sclerosis patients with fecal incontinence that had failed conservative therapy received posterior tibial nerve stimulation between 2012 and 2015. All patients had previously undergone anorectal physiology tests and endoanal ultrasound. Patients whose Wexner incontinence score reduced below 10 post-therapy or halved from baseline were deemed responders. RESULTS Thirty-three patients (25 female, median age 43 years) were included. Twenty-three (70%) had urge, 4 (12%) passive, and 9 (27%) mixed fecal incontinence. Twenty-six (79%) were classified as responders. The majority of subjects had relapsing-remitting multiple sclerosis (67%); those had a significantly higher response rate (95% vs. 67% and 50% in primary and secondary progressive respectively, P < 0.05). Responders tended to be more symptomatic at baseline and had greater improvements in bowel symptom scores and quality of life scores with therapy. CONCLUSION Posterior tibial nerve stimulation demonstrates potential as an effective therapy for fecal incontinence in multiple sclerosis. These findings provide the basis for future more definitive controlled studies.
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Affiliation(s)
| | - Laura Neilan
- School of Medicine, Royal College of Surgeons of Ireland, Dublin, Ireland
| | | | | | - Jorge Liwanag
- GI Physiology Unit, University College London Hospital, London, UK
| | - Amanda Raeburn
- GI Physiology Unit, University College London Hospital, London, UK
| | | | | | - Anton Emmanuel
- GI Physiology Unit, University College London Hospital, London, UK.,School of Medicine, University College London, London, UK
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Arroyo Fernández R, Avendaño Coy J, Ando Lafuente S, Martín Correa MT, Ferri Morales A. Posterior tibial nerve stimulation in the treatment of fecal incontinence: a systematic review. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2018; 110:577-588. [DOI: 10.17235/reed.2018.5007/2017] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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13
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van der Wilt AA, Giuliani G, Kubis C, van Wunnik BPW, Ferreira I, Breukink SO, Lehur PA, La Torre F, Baeten CGMI. Randomized clinical trial of percutaneous tibial nerve stimulation versus sham electrical stimulation in patients with faecal incontinence. Br J Surg 2017; 104:1167-1176. [PMID: 28703936 DOI: 10.1002/bjs.10590] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 01/18/2017] [Accepted: 04/06/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND The aim was to assess the effects of percutaneous tibial nerve stimulation (PTNS) in the treatment of faecal incontinence (FI) by means of an RCT. METHODS Patients aged over 18 years with FI were included in a multicentre, single-blinded RCT. The primary endpoint was reduction in the median or mean number of FI episodes per week. Secondary endpoints were changes in measures of FI severity, and disease-specific and generic quality of life. Outcomes were compared between PTNS and sham stimulation after 9 weeks of treatment. RESULTS A higher proportion of patients in the PTNS (13 of 29) than in the sham (6 of 30) group showed a reduction of at least 50 per cent in the median number of FI episodes/week (incidence rate ratio (IRR) 2·40, 95 per cent c.i. 1·10 to 5·24; P = 0·028), but not in the mean number of episodes/week (10 of 29 versus 8 of 30; IRR 1·42, 0·69 to 2·92; P = 0·347). The absolute median number of FI episodes per week decreased in the PTNS but not in the sham group (IRR 0·66, 0·44 to 0·98; P = 0·041), as did the mean number (IRR 0·65 (0·45 to 0·97); P = 0·034). Scores on the Cleveland Clinic Florida faecal incontinence scale decreased significantly in both groups, but more steeply in the PTNS group (mean difference -1·3, 95 per cent c.i. -2·6 to 0·0; P = 0·049). The aggregated mental component score of Short Form 36 improved in the PTNS but not in the sham group (mean difference 5·1, 0·5 to 9·6; P = 0·028). CONCLUSION PTNS may offer a small advantage in the clinical management of FI that is insufficiently responsive to conservative treatment. The key challenge will be to identify patients who may benefit most from this minimally invasive surgical procedure. Registration number: NCT00974909 (http://www.clinicaltrials.gov).
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Affiliation(s)
- A A van der Wilt
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - G Giuliani
- Department of Surgery, Università degli Studi di Roma 'Sapienza', Rome, Italy
| | - C Kubis
- Department of Surgery, Institut des Maladies de l'Appareil Digestiv, University Hospital of Nantes, Nantes, France
| | - B P W van Wunnik
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - I Ferreira
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands.,Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - S O Breukink
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - P A Lehur
- Department of Surgery, Institut des Maladies de l'Appareil Digestiv, University Hospital of Nantes, Nantes, France
| | - F La Torre
- Department of Surgery, Università degli Studi di Roma 'Sapienza', Rome, Italy
| | - C G M I Baeten
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
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Percutaneous tibial nerve stimulation (pTNS): success rate and the role of rectal capacity. Int J Colorectal Dis 2017; 32:789-796. [PMID: 28391449 DOI: 10.1007/s00384-017-2804-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE Percutaneous tibial nerve stimulation (pTNS) was originally developed to treat urinary incontinence. Recently, some case series have also documented its success in the treatment of fecal incontinence. Nevertheless, the mechanism underlying this effect remains unknown but may be related to changes in rectal capacity. The aim of this study was to investigate the success of pTNS for the treatment of fecal urge incontinence and assess the influence of rectal capacity on treatment efficacy. METHODS All patients undergoing pTNS for fecal incontinence between July 2009 and March 2014 were enrolled in a prospective, observational study consisting of a therapeutic regimen that lasted 9 months. Therapy success was defined as a reduction in the CCI (Cleveland Clinic incontinence) score of ≥50% and patient-reported success. Furthermore, quality of life (Rockwood's scale) and changes in anorectal physiology were recorded. RESULTS Fifty-seven patients with fecal urge incontinence were eligible, nine of whom were excluded. The success rate was 72.5%. Incontinence events and urge symptoms were significantly reduced after 3 months and at the end of therapy. The median CCI score decreased from 12 to 4 (P < 0.0001), and the quality of life was significantly improved. However, rectal capacity was not significantly related to treatment success before or after therapy. No adverse events were observed. CONCLUSIONS These results demonstrate that pTNS can improve the symptoms and quality of life of patients with fecal urge incontinence. However, the study fails to demonstrate a correlation between treatment success and changes in rectal capacity.
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Perspectives From Patients and Care Providers on the Management of Fecal Incontinence: A Needs Assessment. Dis Colon Rectum 2017; 60:408-415. [PMID: 28267009 DOI: 10.1097/dcr.0000000000000768] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND A large proportion of Canadians experience fecal incontinence, with no avenue for effective treatments. The Ottawa Hospital has recently started a percutaneous tibial nerve stimulation program for patients who have not improved with conservative efforts. OBJECTIVE As part of this program implementation, a qualitative needs assessment was undertaken to better define successful outcomes and to identify barriers for program sustainability. DESIGN This was a cross-sectional, qualitative study involving standardized, semistructured interviews. SETTINGS The study was conducted at a single tertiary care center. PATIENTS Patients experiencing fecal incontinence, as well as nurses, physical therapists, and physicians, were enrolled in the study. MAIN OUTCOME MEASURES Interview questions revolved around success definitions, barriers, and promoters of fecal incontinence care. Transcripts were analyzed to develop themes surrounding fecal incontinence care. RESULTS Twelve interviews were undertaken raising a total of 17 different themes. Barriers to fecal incontinence care included education for both the care provider and patients. Access issues for treatments were also highlighted. Promoters of fecal incontinence care were reflected by the impact that it has on quality of life, personal hygiene, psychological burden, and activity and productivity. The definition of fecal incontinence success was focused on improvements in quality of life rather than a numerical reduction of incontinence episodes. LIMITATIONS This study was limited in its small number of interviews conducted. We were unable to identify patients who were unable to seek out care for fecal incontinence. CONCLUSIONS Patient and care provider education surrounding fecal incontinence is lacking. Furthermore, access for effective treatments is a real barrier for Canadians experiencing fecal incontinence. Programs should focus on improvement of overall quality of life rather than a reduction of incontinence episodes.
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Abstract
Fecal incontinence is a highly prevalent and distressing condition that has a negative impact on quality of life. The etiology is often multifactorial, and the evaluation and treatment of this condition can be hindered by a lack of understanding of the mechanisms and currently available treatment options. This article reviews the evidence-based update for the management of fecal incontinence.
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Affiliation(s)
- Isuzu Meyer
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, 1700 6th Avenue South, Suite 10382, Birmingham, AL 35233, USA.
| | - Holly E Richter
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, 1700 6th Avenue South, Suite 10382, Birmingham, AL 35233, USA
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Horrocks EJ, Bremner SA, Stevens N, Norton C, Gilbert D, O'Connell PR, Eldridge S, Knowles CH. Double-blind randomised controlled trial of percutaneous tibial nerve stimulation versus sham electrical stimulation in the treatment of faecal incontinence: CONtrol of Faecal Incontinence using Distal NeuromodulaTion (the CONFIDeNT trial). Health Technol Assess 2016; 19:1-164. [PMID: 26422980 DOI: 10.3310/hta19770] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Faecal incontinence (FI) is a common condition which is often under-reported. It is distressing for those suffering from it, impacting heavily on their quality of life. When conservative strategies fail, treatment options are limited. Percutaneous tibial nerve stimulation (PTNS) is a minimally invasive outpatient treatment, shown in preliminary case series to have significant effectiveness; however, no randomised controlled trial has been conducted. OBJECTIVES To assess the effectiveness of PTNS compared with sham electrical stimulation in the treatment of patients with FI in whom initial conservative strategies have failed. DESIGN Multicentre, parallel-arm, double-blind randomised (1 : 1) controlled trial. SETTING Eighteen UK centres providing specialist nurse-led (or equivalent) treatment for pelvic floor disorders. PARTICIPANTS Participants aged > 18 years with FI who have failed conservative treatments and whose symptoms are sufficiently severe to merit further intervention. INTERVENTIONS PTNS was delivered via the Urgent(®) PC device (Uroplasty Limited, Manchester, UK), a hand-held pulse generator unit, with single-use leads and fine-needle electrodes. The needle was inserted near the tibial nerve on the right leg adhering to the manufacturer's protocol (and specialist training). Treatment was for 30 minutes weekly for a duration of 12 treatments. Validated sham stimulation involved insertion of the Urgent PC needle subcutaneously at the same site with electrical stimulation delivered to the distal foot using transcutaneous electrical nerve stimulation. MAIN OUTCOME MEASURES Outcome measures were assessed at baseline and 2 weeks following treatment. Clinical outcomes were derived from bowel diaries and validated, investigator-administered questionnaires. The primary outcome classified patients as responders or non-responders, with a responder defined as someone having achieved ≥ 50% reduction in weekly faecal incontinence episodes (FIEs). RESULTS In total, 227 patients were randomised from 373 screened: 115 received PTNS and 112 received sham stimulation. There were 12 trial withdrawals: seven from the PTNS arm and five from the sham arm. Missing data were multiply imputed. For the primary outcome, the proportion of patients achieving a ≥ 50% reduction in weekly FIEs was similar in both arms: 39 in the PTNS arm (38%) compared with 32 in the sham arm (31%) [odds ratio 1.28, 95% confidence interval (CI) 0.72 to 2.28; p = 0.396]. For the secondary outcomes, significantly greater decreases in weekly FIEs were observed in the PTNS arm than in the sham arm (beta -2.3, 95% CI -4.2 to -0.3; p = 0.02), comprising a reduction in urge FIEs (p = 0.02) rather than passive FIEs (p = 0.23). No significant differences were found in the St Mark's Continence Score or any quality-of-life measures. No serious adverse events related to treatment were reported. CONCLUSIONS PTNS did not show significant clinical benefit over sham electrical stimulation in the treatment of FI based on number of patients who received at least a 50% reduction in weekly FIE. It would be difficult to recommend this therapy for the patient population studied. Further research will concentrate on particular subgroups of patients, for example those with pure urge FI. TRIAL REGISTRATION Current Controlled Trials ISRCTN88559475. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 77. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Emma J Horrocks
- National Centre for Bowel Research and Surgical Innovation, Blizard Institute, Queen Mary University of London, London, UK
| | - Stephen A Bremner
- Pragmatic Clinical Trials Unit, Blizard Institute, Queen Mary University of London, London, UK
| | - Natasha Stevens
- Pragmatic Clinical Trials Unit, Blizard Institute, Queen Mary University of London, London, UK
| | - Christine Norton
- Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, UK
| | - Deborah Gilbert
- National Centre for Bowel Research and Surgical Innovation, Blizard Institute, Queen Mary University of London, London, UK
| | - P Ronan O'Connell
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| | - Sandra Eldridge
- Pragmatic Clinical Trials Unit, Blizard Institute, Queen Mary University of London, London, UK
| | - Charles H Knowles
- National Centre for Bowel Research and Surgical Innovation, Blizard Institute, Queen Mary University of London, London, UK
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18
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Kelly SL, Radley SC, Brown SR. Does percutaneous tibial nerve stimulation improve global pelvic function in women with faecal incontinence? Colorectal Dis 2016; 18:O158-63. [PMID: 26970061 DOI: 10.1111/codi.13329] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 02/11/2016] [Indexed: 02/08/2023]
Abstract
AIM Percutaneous tibial nerve stimulation (PTNS) is a minimally invasive treatment for faecal incontinence. Many patients with faecal incontinence have coexisting pelvic floor disorders such as urinary incontinence and vaginal symptoms. We utilized a pelvic floor assessment tool to analyse any effect of PTNS on global pelvic floor function. METHODS Patients with faecal incontinence attending our institution who had failed to respond sufficiently to biofeedback were offered a course of PTNS. Patients underwent pre- and post-stimulation assessment with a validated electronic Personal Assessment Questionnaire - Pelvic Floor (ePAQ-PF) for pelvic floor disorders. Scores were compared to assess the effect of treatment on global pelvic floor function. RESULTS During the study period pre- and post-stimulation ePAQ-PF data were available for 60 patients (55% of all patients starting PTNS). In this cohort there was a significant improvement in bowel continence, bowel related quality of life, irritable bowel syndrome and bowel evacuation with a large effect size for continence and bowel related quality of life. There was also a significant improvement in non-bowel related symptoms, including urinary pain and stress incontinence, urinary related quality of life and bowel related sexual function. Sixty-five per cent of those who answered the question reported improvement in global health after stimulation. CONCLUSION For patients presenting with faecal incontinence, PTNS appears to have a positive effect on bowel related function in approximately two-thirds of patients. However, for treatment responders, improvement appears to relate mainly to improvement in bowel related function rather than a global pelvic floor effect.
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Affiliation(s)
- S L Kelly
- Northern General Hospital, Sheffield, UK
| | - S C Radley
- Royal Hallamshire Hospital, Sheffield, UK
| | - S R Brown
- Northern General Hospital, Sheffield, UK
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Meyer I, Richter HE. Impact of fecal incontinence and its treatment on quality of life in women. ACTA ACUST UNITED AC 2015; 11:225-38. [PMID: 25776296 DOI: 10.2217/whe.14.66] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Fecal incontinence (FI) is a physically and psychosocially debilitating disorder which negatively impacts quality of life (QOL). It bears a significant burden not only on patients but also on their families, caretakers as well as society as a whole. Even though it is considered a somewhat common condition, especially as women age, the prevalence is often underestimated due to patients' reluctance to report symptoms or seek care. The evaluation and treatment of FI can be also hindered by lack of understanding of the current management options among healthcare providers and how they impact on QOL. This article provides a comprehensive review on the impact of FI and its treatment on QOL in women.
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Affiliation(s)
- Isuzu Meyer
- Division of Urogynecology & Pelvic Reconstructive Surgery, Department of Obstetrics & Gynecology, University of Alabama at Birmingham, 1700 6th Avenue South, Suite 10382, Birmingham, AL 35233, USA
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Knowles CH, Horrocks EJ, Bremner SA, Stevens N, Norton C, O'Connell PR, Eldridge S. Percutaneous tibial nerve stimulation versus sham electrical stimulation for the treatment of faecal incontinence in adults (CONFIDeNT): a double-blind, multicentre, pragmatic, parallel-group, randomised controlled trial. Lancet 2015; 386:1640-8. [PMID: 26293315 DOI: 10.1016/s0140-6736(15)60314-2] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Percutaneous tibial nerve stimulation (PTNS) is a new ambulatory therapy for faecal incontinence. Data from case series suggest it has beneficial outcomes in 50-80% patients; however its effectiveness against sham electrical stimulation has not been investigated. We therefore aimed to assess the short-term efficacy of PTNS against sham electrical stimulation in adults with faecal incontinence. METHODS We did a double-blind, multicentre, pragmatic, parallel-group, randomised controlled trial (CONtrol of Faecal Incontinence using Distal NeuromodulaTion [CONFIDeNT]) in 17 specialist hospital units in the UK that had the skills to manage patients with faecal incontinence. Eligible participants aged 18 years or older with substantial faecal incontinence for whom conservative treatments (such as dietary changes and pelvic floor exercises) had not worked, were randomly assigned (1:1) to receive either PTNS (via the Urgent PC neuromodulation system) or sham stimulation (via a transcutaneous electrical nerve stimulation machine to the lateral forefoot) once per week for 12 weeks. Randomisation was done with permuted block sizes of two, four, and six, and was stratified by sex and then by centre for women. Patients and outcome assessors were both masked to treatment allocation for the 14-week duration of the trial (but investigators giving the treatment were not masked). The primary outcome was a clinical response to treatment, which we defined as a 50% or greater reduction in episodes of faecal incontinence per week. We assessed this outcome after 12 treatment sessions, using data from patients' bowel diaries. Analysis was by intention to treat, and missing data were multiply imputed. This trial is registered with the ISRCTN registry, number 88559475, and is closed to new participants. FINDINGS Between Jan 23, 2012, and Oct 31, 2013, we randomly assigned 227 eligible patients (of 373 screened) to receive either PTNS (n=115) or sham stimulation (n=112). 12 patients withdrew from the trial: seven from the PTNS group and five from the sham group (mainly because they could not commit to receiving treatment every week). Two patients (one in each group) withdrew because of an adverse event that was unrelated to treatment (exacerbation of fibromyalgia and rectal bleeding). 39 (38%) of 103 patients with full data from bowel diaries in the PTNS group had a 50% or greater reduction in the number of episodes of faecal incontinence per week compared with 32 (31%) of 102 patients in the sham group (adjusted odds ratio 1·28, 95% CI 0·72-2·28; p=0·396). No serious adverse events related to treatment were reported in the trial. Seven mild, related adverse events were reported in each treatment group, mainly pain at the needle site (four in PTNS, three in sham). INTERPRETATION PTNS given for 12 weeks did not confer significant clinical benefit over sham electrical stimulation in the treatment of adults with faecal incontinence. Further studies are warranted to determine its efficacy in the long term, and in patient subgroups (ie, those with urgency). FUNDING National Institute for Health Research.
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Affiliation(s)
- Charles H Knowles
- National Centre for Bowel Research and Surgical Innovation, Blizard Institute, Queen Mary University of London, London, UK.
| | - Emma J Horrocks
- National Centre for Bowel Research and Surgical Innovation, Blizard Institute, Queen Mary University of London, London, UK
| | - Stephen A Bremner
- Pragmatic Clinical Trials Unit, Blizard Institute, Queen Mary University of London, London, UK
| | - Natasha Stevens
- Pragmatic Clinical Trials Unit, Blizard Institute, Queen Mary University of London, London, UK
| | - Christine Norton
- Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, UK
| | - P Ronan O'Connell
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| | - Sandra Eldridge
- Pragmatic Clinical Trials Unit, Blizard Institute, Queen Mary University of London, London, UK
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Meyer I, Richter HE. Evolving Surgical Treatment Approaches for Fecal Incontinence in Women. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2015. [DOI: 10.1007/s13669-015-0116-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Pregnancy and postpartum bowel changes: constipation and fecal incontinence. Am J Gastroenterol 2015; 110:521-9; quiz 530. [PMID: 25803402 DOI: 10.1038/ajg.2015.76] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 02/10/2015] [Indexed: 12/11/2022]
Abstract
Pregnancy and the postpartum period are often associated with many gastrointestinal complaints, including nausea, vomiting, and heartburn; however, the most troublesome complaints in some women are defecatory disorders such as constipation and fecal incontinence, especially postpartum. These disorders are often multifactorial in etiology, and many studies have looked to see what risk factors lead to these complications. This review discusses the current knowledge of pelvic floor and anorectal physiology, especially during pregnancy, and reviews the current literature on causes and treatments of postpartum bowel symptoms of constipation and fecal incontinence.
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