Selecting an outcome measure for evaluating treatment in fecal incontinence

Anal incontinence after obstetrical anal sphincter injury significantly impacts quality of life for women: a cohort study

PURPOSE

To assess the prevalence of anal incontinence (AI) after obstetrical anal sphincter injuries (OASIS) and its severity, as well as the risk factors for AI and AI episodes ≥ 6 months.

METHODS

This prospective and observational monocentric cohort study included all the women who had an OASIS between 1 January 2005 and 31 December 2019. Information was collected by using a letter informing for the fecal incontinence quality of life (FIQL) questionnaire and by a phone interview. The main outcome measure was "1 passed or ongoing episode of AI".

RESULTS

Among the 227 patients included, 19.8% had ongoing AI, and 35.2% had AI passed or ongoing episodes. A total of 46.7% of women with AI reported a change in their quality of life in all fields of the FIQL. Excluding a history of inflammatory bowel disease, no factor was associated with the incidence of an AI episode. Post-obstetrical AI ≥ 6 months (POAI ≥ 6) represented 63.7% of AI cases. This incontinence began with significant incidence in the immediate postpartum period but increased over time, unlike AI < 6 months, which appeared primarily in the immediate postpartum period. Instrumental birth was a protective factor for POAI ≥ 6 (OR = 0.24; CI 95% [0.08-0.78]; p = 0.016), while an increase in parity and BMI were risk factors for POAI ≥ 6 (OR = 4.21; CI 95% [1.01-17.71]; p = 0.05 and OR = 1.15; CI 95% [1.03-1.30]; p = 0.016, respectively).

CONCLUSION

The prevalence of AI after OASIS is not underestimated. Despite the fact that women do not seek care, the impact of AI on the quality of life is significant. A case of AI that lasts for 6 months after giving birth risks becoming chronic. Therefore, specialist advice should be recommended in this case.

CLINICAL TRIAL REGISTRY

NCT04940494.

Use of a motion-based digital therapeutic in women with fecal incontinence: A pilot study

AIMS

There is limited data addressing the value of vaginal biofeedback (VBF) on fecal incontinence (FI) symptoms. The objective of this pilot study was to evaluate whether use of a motion-based VBF device and app was effective for at-home treatment of women with FI. We hypothesized that VBF would result in improvement in FI symptoms.

METHODS

A single-arm 10-week prospective pilot trial in women with FI was conducted using the VBF device. The primary outcome was change in St. Mark's score from baseline to week 10. Secondary outcomes included change in 2-week bowel diary and FI quality of life (FIQoL). Statistical analysis included paired t test and Wilcoxon's signed-rank test.

RESULTS

Of 29 enrolled women, 27 had data available for analysis. Mean (±SD) age was 60.9 (±14.4). 63% (17) subjects were White, 33% (9) were Black. Mean St. Mark's score was 14.6 (±4.4) at baseline and 11.6 (±5.1) at 10-weeks (p = 0.005). Changes in the total FIQol, and three of four subsets of the FIQoL scores were also significantly improved (p < 0.001). Bowel diary showed decrease in FI episodes, baseline 8.4 (±8.73) to 10 weeks 4.8 (±3.79), (p = 0.052).

CONCLUSIONS

In this pilot study, there was significant improvement in FI symptom-specific severity and quality of life using a vaginal, motion-based device for biofeedback. A larger study is needed to better understand the value of this device, which may be useful for women who prefer a vaginal device, which can be utilized at home compared with standard anal biofeedback for treatment of FI in the clinical setting.

Oncological and Functional Outcomes of Transanal Total Mesorectal Excision in a Teaching Hospital in the Netherlands

Purpose

Transanal total mesorectal excision (TaTME) was developed to overcome surgical difficulties experienced in distal pelvic dissection. Concerns have been raised about potential worse postoperative functional outcomes after TaTME. Also, the oncological safety was questioned. This study aimed to describe the functional, surgical, oncological outcomes and quality of life (QoL) after TaTME.

Methods

All consecutive TaTME cases for rectal cancer without disseminated disease between December 2016 and April 2019 were included. The Wexner incontinence score, low anterior resection syndrome (LARS) score, fecal incontinence-related QoL, and the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-core questionnaire and 29-item module (EORTC QLQ-C30/CR29) were collected. Kaplan-Meier analysis was used to calculate local recurrence-free survival.

Results

Thirty patients were eligible for analysis of which 23 received questionnaires. Response rate was 74%. After a median follow-up of respectively 20.0 and 23.0 months for functional and oncological outcomes, the median (interquartile range) of Wexner incontinence and LARS scores were 9.0 (7.0-12.0) and 33.1 (25.0-39.0). Major LARS was present in 73.3%. Fecal incontinence, general and colorectal-specific QoL subdomains that are associated with poor bowel function scored in line with previously reported data. The 2-year actuarial cumulative local recurrence rate was 3.7% (95% confidence interval, 2.4%-5.0%).

Conclusion

TaTME may lead to significant functional impairments. Patients should receive preoperative counseling on this topic and be fully aware of the potential consequences of their treatment. Oncological data were in line with other short- to moderate-term data and did not show alarming results.

Functional complaints and quality of life after transanal total mesorectal excision: a meta-analysis

BACKGROUND

Total mesorectal excision (TME) gives excellent oncological results in rectal cancer treatment, but patients may experience functional problems. A novel approach to performing TME is by single-port transanal minimally invasive surgery. This systematic review evaluated the functional outcomes and quality of life after transanal and laparoscopic TME.

METHODS

A comprehensive search in PubMed, the Cochrane Library, Embase and the trial registers was conducted in May 2019. PRISMA guidelines were used. Data for meta-analysis were pooled using a random-effects model.

RESULTS

A total of 11 660 studies were identified, from which 14 studies and six conference abstracts involving 846 patients (599 transanal TME, 247 laparoscopic TME) were included. A substantial number of patients experienced functional problems consistent with low anterior resection syndrome (LARS). Meta-analysis found no significant difference in major LARS between the two approaches (risk ratio 1·13, 95 per cent c.i. 0·94 to 1·35; P = 0·18). However, major heterogeneity was present in the studies together with poor reporting of functional baseline assessment.

CONCLUSION

No differences in function were observed between transanal and laparoscopic TME.

Pelvic floor rehabilitation to improve functional outcome and quality of life after surgery for rectal cancer: study protocol for a randomized controlled trial (FORCE trial)

BACKGROUND

After low anterior resection (LAR), up to 90% of patients develop anorectal dysfunction. Especially fecal incontinence has a major impact on the physical, psychological, social, and emotional functioning of the patient but also on the Dutch National Healthcare budget with more than €2000 spent per patient per year. No standardized treatment is available to help these patients. Common treatment nowadays is focused on symptom relief, consisting of lifestyle advices and pharmacotherapy with bulking agents or antidiarrheal medication. Another possibility is pelvic floor rehabilitation (PFR), which is one of the most important treatments for fecal incontinence in general, with success rates of 50-80%. No strong evidence is available for the use of PFR after LAR. This study aims to prove a beneficial effect of PFR on fecal incontinence, quality of life, and costs in rectal cancer patients after sphincter-saving surgery compared to standard treatment.

METHODS

The FORCE trial is a multicenter, two-armed, randomized clinical trial. All patients that underwent LAR are recruited from the participating hospitals and randomized for either standard treatment or a standardized PFR program. A total of 128 patients should be randomized. Optimal blinding is not possible. Stratification will be done in variable blocks (gender and additional radiotherapy). The primary endpoint is the Wexner incontinence score; secondary endpoints are health-related and fecal-incontinence-related QoL and cost-effectiveness. Baseline measurements take place before randomization. The primary endpoint is measured 3 months after the start of the intervention, with a 1-year follow-up for sustainability research purposes.

DISCUSSION

The results of this study may substantially improve postoperative care for patients with fecal incontinence or anorectal dysfunction after LAR. This section provides insight in the decisions that were made in the organization of this trial.

TRIAL REGISTRATION

Netherlands Trial Registration, NTR5469, registered on 03-09-2015. Protocol FORCE trial V18, 19-09-2019. Sponsor Radboud University Medical Center, Nijmegen.

Sacral neuromodulation versus onabotulinumtoxinA for refractory urgency urinary incontinence: impact on fecal incontinence symptoms and sexual function

BACKGROUND

Women with refractory urgency urinary incontinence can be treated with onabotulinumtoxinA or sacral neuromodulation. Little data exists on the comparative effects of treatment of refractory urgency urinary incontinence on other pelvic floor complaints, such as bowel and sexual function.

OBJECTIVE

The objective of this study was to compare the impact of these treatments on fecal incontinence and sexual symptoms.

METHODS

This was a planned supplemental analysis of a randomized trial in women with refractory urgency urinary incontinence treated with onabotulinumtoxinA (n = 190) or sacral neuromodulation (n = 174). Fecal incontinence and sexual symptoms were assessed at baseline and at 6, 12, and 24 months. Fecal incontinence symptoms were measured using the St Mark's (Vaizey) Fecal Incontinence severity scale. Sexual symptoms were measured using the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 (PISQ-12) and the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR). The PISQ-IR allows measurement of sexual symptoms in both sexually active and non-sexually active adults. Primary outcomes were change in Vaizey and PISQ-12 scores between baseline and 6 months. Secondary outcomes were change in PISQ-IR total and subscores between baseline and 6 months and change in Vaizey, PISQ-12, and PISQ-IR scores between baseline and 12 and 24 months. Intent-to-treat analysis was performed using repeated measures mixed model to estimate change in all parameters from baseline while adjusting for the baseline score. A subgroup analysis of women with clinically significant bowel symptoms was conducted based on baseline Vaizey score of ≥12.

RESULTS

At baseline, mean Vaizey scores were indicative of mild fecal incontinence symptoms and were not different between onabotulinumtoxinA and sacral neuromodulation groups (7.6 ± 5.3 vs 6.6 ± 4.9, P = .07). The proportion of sexually active women (56% vs 63%, P = .25), mean PISQ-12 score (33.4 ± 7.5 vs 32.7 ± 6.7, P = .55), or PISQ-IR subscores were also not different between the onabotulinumtoxinA and sacral neuromodulation groups at baseline. There was no difference between women treated with onabotulinumtoxinA and those treated with sacral neuromodulation at 6 months in terms of improvement in fecal incontinence symptom score (Vaizey: -1.9, 95% confidence interval -2.6 to -1.2 vs -0.9, 95% confidence interval -1.7 to -0.2, P = .07) or sexual symptoms score (PISQ-12: 2.2, 95% confidence interval 0.7 to 3.7 vs 2.2, 95% confidence interval 0.7 to 3.7, P = .99). There was no difference in improvement between groups in the sexual symptom subscores in sexually active and non-sexually active women at 6 months. Similar findings were noted at 12 and 24 months. In a subgroup (onabotulinumtoxinA = 33 and sacral neuromodulation = 22) with clinically significant fecal incontinence at baseline (Vaizey score ≥12), there was a clinically meaningful improvement in symptoms in both groups from baseline to 6 months, with no difference in improvement between the onabotulinumtoxinA and sacral neuromodulation groups (-5.1, 95% confidence interval -7.3 to -2.8 vs -5.6, 95% confidence interval -8.5 to -2.6, P = .8).

CONCLUSION

There were no differences in improvement of fecal incontinence and sexual symptoms in women with urgency urinary incontinence treated with onabotulinumtoxinA or sacral neuromodulation. Women with significant fecal incontinence symptoms at baseline had clinically important improvement in symptoms, with no difference between the treatments. Our findings can help clinicians counseling women considering treatment for refractory urgency urinary incontinence.

Relationship between symptoms and quality of life in fecal incontinence

BACKGROUND

Most measures of fecal incontinence (FI) severity assess the frequency of solid and liquid FI, but may incorporate other features. We compared two scales-the Fecal Incontinence Severity Score (FISS) and Fecal Incontinence Severity Index (FISI)-to determine which questionnaire and which individual questions predict FI Quality of Life (FIQOL).

METHODS

A national sample of American adults completed a health questionnaire, and 234 with monthly FI were selected. Participants completed assessments of FI severity, FIQOL, and somatization. Stepwise linear regression models evaluated whether FISS and FISI total scores, or individual items on the FISS and FISI predicted FIQOL after adjusting for gender, age, income, and somatization (Brief Symptom Inventory-18).

KEY RESULTS

Reliable responses were provided by 186. Age was 49 years, and 52% were women. The mean FISS score was 8.4 (95% confidence interval [CI] 8.0-8.9, 13 questions) and mean FISI was 29.9 (95% CI 27.4-32.4, 62 questions), indicating moderate FI severity. The mean FIQOL was 2.6 (95% CI 2.4-2.7, 5 questions). Lower income, greater somatization, and total FISS and FISI scores explained 69% of FIQOL; and total FISS and FISI scores were independent predictors. On the FISS, frequency, amount, and urgency to defecate were independently associated with FIQOL. After adding somatization, all but amount remained significant. For the FISI scale, solid and liquid FI and gas were significant predictors, but adjusting for somatization excluded solid FI.

CONCLUSIONS AND INFERENCES

Five variables independently explained FIQOL: overall frequency of FI, frequency of liquid and gas leakage, urgency, and somatization.

Controlling anal incontinence in women by performing anal exercises with biofeedback or loperamide (CAPABLe) trial: Design and methods

The goals of this trial are to determine the efficacy and safety of two treatments for women experiencing fecal incontinence. First, we aim to compare the use of loperamide to placebo and second, to compare the use of anal sphincter exercises with biofeedback to usual care. The primary outcome is the change from baseline in the St. Mark's (Vaizey) Score 24weeks after treatment initiation. As a Pelvic Floor Disorders Network (PFDN) trial, subjects are enrolling from eight PFDN clinical centers across the United States. A centralized data coordinating center supervises data collection and analysis. These two first-line treatments for fecal incontinence are being investigated simultaneously using a two-by-two randomized factorial design: a medication intervention (loperamide versus placebo) and a pelvic floor strength and sensory training intervention (anal sphincter exercises with manometry-assisted biofeedback versus usual care using an educational pamphlet). Interventionists providing the anal sphincter exercise training with biofeedback have received standardized training and assessment. Symptom severity, diary, standardized anorectal manometry and health-related quality of life outcomes are assessed using validated instruments administered by researchers masked to randomized interventions. Cost effectiveness analyses will be performed using prospectively collected data on care costs and resource utilization. This article describes the rationale and design of this randomized trial, focusing on specific research concepts of interest to researchers in the field of female pelvic floor disorders and all other providers who care for patients with fecal incontinence.

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

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

Home electrical stimulation for women with fecal incontinence: a preliminary randomized controlled trial

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.

Pelvic floor muscle training for bowel dysfunction following colorectal cancer surgery: A systematic review

AIMS

To identify, evaluate and synthesize the evidence examining the effectiveness of pelvic floor muscle training (PFMT) on bowel dysfunction in patients who have undergone colorectal cancer surgery.

METHODS

Eight electronic databases (MEDLINE 1950-2014; CINAHL 1982-2014; EMBASE 1980-2014; Scopus 1823-2014; PsycINFO 1806-2014; Web of Science 1970-2014; Cochrane Library 2014; PEDro 1999-2014) were systematically searched in March 2014. Reference lists of identified articles were cross referenced and hand searched. Randomized controlled trials, cohort studies and case series were included if they investigated the effects of conservative treatments, including PFMT on bowel function in patients with colorectal cancer following surgery. Two reviewers independently assessed the risk of bias of studies using the Newcastle-Ottawa Scale (NOS).

RESULTS

Six prospective non-randomized studies and two retrospective studies were included. The mean (SD) NOS risk of bias score was 4.9 (1.2) out of 9; studies were limited by a lack of non-exposed cohort, lack of independent blinded assessment, heterogeneous treatment protocols, and lack of long-term follow-up. The majority of studies reported significant improvements in stool frequency, incontinence episodes, severity of fecal incontinence, and health-related quality of life (HRQoL) after PFMT. Meta-analysis was not possible due to lack of randomized controlled trials.

CONCLUSIONS

Pelvic floor muscle training for patients following surgery for colorectal cancer appears to be associated with improvements in bowel function and HRQoL. Results from non-randomized studies are promising but randomized controlled trials with sufficient power are needed to confirm the effectiveness of PFMT in this population.

Responsiveness and interpretability of incontinence severity scores and FIQL in patients with fecal incontinence: a secondary analysis from a randomized controlled trial

INTRODUCTION AND HYPOTHESIS

This study aims to assess the responsiveness and interpretability of the Vaizey score, Wexner score, and the Fecal Incontinence Quality of Life Scale (FIQL) for use in the evaluation of patients with fecal incontinence (FI).

METHODS

Eighty patients with FI with a mean age of 59.3 (SD ± 11.9) were enrolled in a randomized controlled trial. The patient-reported outcomes were tested for internal and external responsiveness, longitudinal construct validity, and interpretability.

RESULTS

All total scores proved to have both adequate to excellent responsiveness and longitudinal construct validity, and changes were in agreement with subjective improvement. Due to variability in minimally important change estimates (Vaizey score -5 to -3, Wexner score -3 to -2, FIQL 1.1 to 1.2), they should be used as indicators. All patient-reported outcomes showed psychometric or practical limitations.

CONCLUSIONS

The instruments available to date to evaluate severity and quality of life in FI do not yet attain the highest levels of psychometric soundness. As the focus of patients may differ from that of physicians, it is recommended that several measures should be included for evaluation. So far, there are suggestions that the Wexner score is most suitable for severity assessment and the FIQL for evaluating quality of life.

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

Sacral nerve stimulation for fecal incontinence: long-term outcomes

BACKGROUND

Numerous studies advocate the short-term benefits of sacral nerve stimulation for fecal incontinence, but there has been a paucity of studies on longer-term outcomes.

OBJECTIVE

The objective of this study was to report the long-term outcome of sacral nerve stimulation performed for fecal incontinence at a single institution.

PATIENTS AND DESIGN

Between January 2004 and May 2007, 53 patients underwent definitive sacral nerve stimulation for fecal incontinence at our institution. Prospectively recorded baseline information, including Wexner incontinence scores and standard short-form (SF-12) health survey scores, were compared with scores at follow-up.

RESULTS

Forty-one patients were available for long-term follow-up with a mean duration of 51 months. The median Wexner score decreased from a baseline of 11.5 (range, 3.0-18.0) to 8.0 (range, 0.0-18.0) at follow-up. The mean difference in Wexner score was 2.7 (P < .001). There was no statistically significant change in SF-12 physical scores, but a small but highly significant change occurred in SF-12 mental scores. The median SF-12 mental domain score was 49.5 (range, 15.0-62.1) at baseline, and 57.0 (range, 20.0-64.0) at follow-up, with a mean difference of 4.5 (P = .006). Subgroup analysis performed comparing patients with or without prior intersphincteric silicon biomaterial implants demonstrated a mean difference in Wexner score of -3.5 (no implant) vs 0.0 (previous implant), with P < .09 (not statistically significant).

CONCLUSIONS

Sacral nerve stimulation results in a statistically significant improvement in fecal incontinence scores in the long term.

Utility preference score measurement in women with fecal incontinence

OBJECTIVE

The objective of the study was to evaluate the construct validity of 3 multiattribute health status classification system instruments, and a visual analog scale (VAS) for measuring utility scores for women with fecal incontinence (FI).

STUDY DESIGN

Utility scores were measured in 200 women with 1 or more of the following diagnoses: fecal or urinary incontinence or pelvic organ prolapse. Pelvic floor symptom severity was measured using the Pelvic Floor Distress Inventory (PFDI-20), and quality of life was assessed with the Pelvic Floor Impact Questionnaire (PFIQ-7). Construct and concurrent validity were evaluated.

RESULTS

After adjusting for age, comorbidities, urinary incontinence, and prolapse, utility scores were significantly lower for women with FI than women without FI for all health status instruments but not the VAS. All health status instruments had significant correlations with PFDI-20 and PFIQ-7 scores.

CONCLUSION

The health status instruments provide valid utility scores in women with FI and would be useful in clinical trials and cost-effectiveness research.

Inconclusive psychometric properties of the Vaizey score in fecally incontinent patients: a prospective cohort study

AIM

To determine the psychometric properties of the total Vaizey score and its individual items.

METHODS

The study was conducted as part of a prospective cohort study assessing the outcome of pelvic floor rehabilitation in patients with fecal incontinence.

RESULTS

One hundred ninety-four patients were analyzed, 53 of whom provided data on the global perceived effect (GPE) score. Pelvic floor rehabilitation resulted in a significant reduction of the total Vaizey score and most individual items. The total Vaizey scores changed in agreement with the GPE scores. The total Vaizey score was responsive, but some individual items yielded inconsistent results for three different measures. The test-retest reliability was adequate or excellent for six individual items and the total Vaizey score. The internal consistency was low for the total Vaizey score at baseline, in contrast to the follow-up and change scores. The estimates for the minimally important change (MIC) and smallest detectable change yielded moderately consistent results. An MIC of -5 points seemed preferable and yielded the lowest misclassification rate.

CONCLUSIONS

More research is required to confirm conclusions on the psychometric properties of the total Vaizey score and its individual items, and to justify its use in research and routine clinical practice.

Biofeedback therapy plus anal electrostimulation for fecal incontinence: prognostic factors and effects on anorectal physiology

BACKGROUND

The current literature does not provide unequivocal data on prognostic factors in conservative management of fecal incontinence. Moreover, the physiopathologic effects of pelvic floor rehabilitation on anorectal function are not well understood. Our aim is to identify some prognostic parameters and assess their effects on anorectal physiology of biofeedback therapy plus anal electrostimulation for fecal incontinence.

METHODS

We studied prospectively 45 consecutive adult patients with fecal incontinence treated at our institution with biofeedback plus electrostimulation. The outcome parameter was modification of the Wexner Incontinence Score (WIS) at the end of treatment. In addition, we studied the modifications of anorectal manometry and the rectal sensitivity threshold after treatment.

RESULTS

At univariate analysis, age, the pretreatment WIS, and the pretreatment resting and maximum squeeze pressures were correlated with the clinical outcome. Patients showed a significant reduction in the rectal sensitivity threshold but no significant change in manometric parameters after treatment.

CONCLUSIONS

We identify good sphincter function and mild to moderate symptomatology as favorable prognostic factors in biofeedback and anal electrostimulation therapy. Improvement in rectal sensitivity can be implicated in symptomatic improvement. The impossibility of correlating the clinical results with the effects on anorectal physiology suggests a nonspecific effect of conservative treatment.

Pelvic floor consequences of cesarean delivery on maternal request in women with a single birth: a cost-effectiveness analysis

BACKGROUND

The potential benefit in preventing pelvic floor disorders (PFDs) is a frequently cited reason for requesting or performing cesarean delivery on maternal request (CDMR). However, for primigravid women without medical/obstetric indications, the lifetime cost-effectiveness of CDMR remains unknown, particularly with regard to lifelong pelvic floor consequences. Our objective was to assess the cost-effectiveness of CDMR in comparison to trial of labor (TOL) for primigravid women without medical/obstetric indications with a single childbirth over their lifetime, while explicitly accounting for the management of PFD throughout the lifetime.

METHODS

We used Monte Carlo simulation of a decision model containing 249 chance events and 101 parameters depicting lifelong maternal and neonatal outcomes in the following domains: actual mode of delivery, emergency hysterectomy, transient maternal morbidity and mortality, perinatal morbidity and mortality, and the lifelong management of PFDs. Parameter estimates were obtained from published literature. The analysis was conducted from a societal perspective. All costs and quality-adjusted life-years (QALYs) were discounted to the present value at childbirth.

RESULTS

The estimated mean cost and QALYs were $14,259 (95% confidence interval [CI] $8,964-$24,002) and 58.21 (95% CI 57.43-58.67) for CDMR and $13,283 (95% CI $7,861-$23,829) and 57.87 (95% CI 56.97-58.46) for TOL over the combined lifetime of the mother and the child. Parameters related to PFDs play an important role in determining cost and quality of life.

CONCLUSIONS

When a woman without medical/obstetric indications has only one childbirth in her lifetime, cost-effectiveness analysis does not reveal a clearly preferable mode of delivery.

Anal pressure in experimental diabetes

PURPOSE

Diabetes mellitus is a metabolic endocrine disorder that affects many systems, the gastrointestinal system often being among the affected systems. This experimental study work was designed to demonstrate altered anal sphincter pressures in an experimental model of diabetes mellitus (DM).

MATERIALS AND METHODS

Male Wistar rats (mean weight = 250 g) were used and randomized in two groups (n = 10): CO = control and DM. DM was induced by administering a single dose of streptozotocin. Glycemic levels were measured at the start (time = 0) and end (time = 60) of the experiment and anorectal manometry at the end.

RESULTS

DM rats presented a significant increase in glycemia at day 60 (DM = 407.14 +/- 73.76) as compared to the control group (time 0 = 175.7 +/- 18.62 and time 60 = 198.04 +/- 28.66). Anorectal manometry showed a significant decrease in anal pressure in the DM group at day 60 (DM = 34.2 +/- 4.97) as compared to the CO group at the same time (CO = 67.4 +/- 2.06), with P < 0.01 and P < 0.001 (Student's t test).

CONCLUSIONS

The results suggest that DM, due to the high glycemic levels, lead to alterations such as anal sphincter hypotony, which may cause complications such as fecal incontinence.

Radiofrequency energy delivery to the anal canal: is it a promising new approach to the treatment of fecal incontinence?

BACKGROUND

The present study was conducted to assess the efficacy and safety of the delivery of radiofrequency energy to the anal canal (the SECCA procedure).

METHODS

Eight patients with fecal incontinence underwent the SECCA procedure. The Fecal Incontinence Severity Index (FISI) score and the Fecal Incontinence-related Quality of Life (FIQL) scale were completed at baseline and after the procedure. Anorectal manometry and endoanal ultrasound also were conducted.

RESULTS

Seven of the 8 patients were women, and the median age of the patients was 59 years (range, 28-73 y). The mean FISI score and all of the parameters in the FIQL scale with the exception of the embarrassment scale measured at 6 months after the procedure was not improved significantly. We observed no changes in the anal manometry and endoanal ultrasound parameters. Complications associated with the procedure developed in 7 of the 8 patients, including anal bleeding, anal pain, and anal mucosal discharge.

CONCLUSIONS

The FISI score and FIQL scale were not improved significantly after the SECCA procedure, and considerable complications were associated with the procedure.

Can the outcome of pelvic-floor rehabilitation in patients with fecal incontinence be predicted?

PURPOSE

Pelvic-floor rehabilitation does not provide the same degree of relief in all fecal incontinent patients. We aimed at studying prospectively the ability of tests to predict the outcome of pelvic-floor rehabilitation in patients with fecal incontinence.

MATERIALS AND METHODS

Two hundred fifty consecutive patients (228 women) underwent medical history and a standardized series of tests, including physical examination, anal manometry, pudendal nerve latency testing, anal sensitivity testing, rectal capacity measurement, defecography, endoanal sonography, and endoanal magnetic resonance imaging. Subsequently, patients were referred for pelvic-floor rehabilitation. Outcome of pelvic-floor rehabilitation was quantified by the Vaizey incontinence score. Linear regression analyses were used to identify candidate predictors and to construct a multivariable prediction model for the posttreatment Vaizey score.

RESULTS

After pelvic-floor rehabilitation, the mean baseline Vaizey score (18, SD+/-3) was reduced with 3.2 points (p<0.001). In addition to the baseline Vaizey score, three elements from medical history were significantly associated with the posttreatment Vaizey score (presence of passive incontinence, thin stool consistency, primary repair of a rupture after vaginal delivery at childbed) (R2, 0.18). The predictive value was significantly but marginally improved by adding the following test results: perineal and/or perianal scar tissue (physical examination), and maximal squeeze pressure (anal manometry; R2, 0.20; p=0.05).

CONCLUSION

Additional tests have a limited role in predicting success of pelvic-floor rehabilitation in patients with fecal incontinence.

Does the St. Mark's incontinence score reflect patients' perceptions? A review of 390 patients

PURPOSE

The St. Mark's incontinence score is widely used to evaluate the severity of fecal incontinence. It is unknown to what extent such scores relate to patients' perceptions about their condition. The primary goal of this study was to assess this correlation. Secondary goals were to evaluate the relationship between different types of incontinence, age, gender, and the continence score and to assess the sensitivity of St. Mark's incontinence score to a change in patients' perception and outcome evaluation after treatment.

METHODS

Patients' subjective perception of bowel control (using a 0-10 scale) and St. Mark's incontinence score for 390 patients were reviewed. Change in the score was documented for 131 patients who underwent biofeedback treatment and compared with patients' outcome evaluation.

RESULTS

There was a moderate correlation between patients' perception of bowel control and the St. Mark's incontinence score (r = -0.55; P < 0.001). The correlation was maintained, regardless of type of incontinence (r = -0.48 to -0.55), age (</=60 years: r = -0.54; >60 years: r = -0.58; P < 0.001) or gender (male: r = -0.48; female: r = -0.53; P < 0.001) of patients. St. Mark's incontinence score was sensitive to a change in patients' subjective evaluation after the treatment.

CONCLUSIONS

The St. Mark's incontinence score correlates moderately well with patients' subjective perception and is reliable regardless of the type of incontinence, patients' age, or gender. It is suitable for the severity assessment of fecal incontinence and the evaluation of a treatment outcome.

Referral for anorectal function evaluation is indicated in 65% and beneficial in 92% of patients

AIM: To determine the indicated referrals to a tertiary centre for patients with anorectal symptoms, the effect of the advised treatment and the discomfort of the tests.

METHODS: In a retrospective study, patients referred for anorectal function evaluation (AFE) between May 2004 and October 2006 were sent a questionnaire, as were the doctors who referred them. AFE consisted of anal manometry, rectal compliance measurement and anal endosonography. An indicated referral was defined as needing AFE to establish a diagnosis with clinical consequence (fecal incontinence without diarrhea, 3^rd degree anal sphincter rupture, congenital anorectal disorder, inflammatory bowel disease with anorectal complaints and preoperative in patients for re-anastomosis or enterostoma, anal fissure, fistula or constipation). Anal ultrasound is always indicated in patients with fistula, anal manometry and rectal compliance when impaired continence reserve is suspected. The therapeutic effect was noted as improvement, no improvement but reassurance, and deterioration.

RESULTS: From the 216 patients referred, 167 (78%) returned the questionnaire. The referrals were indicated in 65%. Of these, 80% followed the proposed advice. Improvement was achieved in 35% and a reassurance in 57% of the patients, no difference existed between patient groups. On a VAS scale (1 to 10) symptoms improved from 4.0 to 7.2. Most patients reported no or little discomfort with AFE.

CONCLUSION: Referral for AFE was indicated in 65%. Beneficial effect was seen in 92%: 35% improved and 57% was reassured. Advice was followed in 80%. Better instruction about indication for AFE referral is warranted.

A randomized physiotherapy trial in patients with fecal incontinence: design of the PhysioFIT-study

Background

Fecal incontinence (FI) is defined as the recurrent involuntary excretion of feces in inappropriate places or at inappropriate times. It is a major and highly embarrassing health care problem which affects about 2 to 24% of the adult population. The prevalence increases with age in both men and women.

Physiotherapy interventions are often considered a first-line approach due to its safe and non-invasive nature when dietary and pharmaceutical treatment fails or in addition to this treatment regime. Two physiotherapy interventions, rectal balloon training (RBT) and pelvic floor muscle training (PFMT) are widely used in the management of FI. However, their effectiveness remains uncertain since well-designed trials on the effectiveness of RBT and PFMT versus PFMT alone in FI have never been published.

Methods/Design

A two-armed randomized controlled clinical trial will be conducted. One hundred and six patients are randomized to receive either PFMT combined with RBT or PFMT alone. Physicians in the University Hospital Maastricht include eligible participants. Inclusion criteria are (1) adults (aged ≥ 18 years), (2) with fecal incontinence complaints due to different etiologies persisting for at least six months, (3) having a Vaizey incontinence score of at least 12, (4) and failure of conservative treatment (including dietary adaptations and pharmacological agents). Baseline measurements consist of the Vaizey incontinence score, medical history, physical examination, medication use, anorectal manometry, rectal capacity measurement, anorectal sensation, anal endosonography, defecography, symptom diary, Fecal Incontinence Quality of Life scale (FIQL) and the PREFAB-score. Follow-up measurements are scheduled at three, six and 12 months after inclusion. Skilled and registered physiotherapists experienced in women's health perform physiotherapy treatment. Twelve sessions are administered during three months according to a standardized protocol.

Discussion

This section discusses the decision to publish a trial protocol, the actions taken to minimize bias and confounding in the design, explains the choice for two treatment groups, discusses the secondary goals of this study and indicates the impact of this trial on clinical practice.

Trial registration

The Netherlands Trial Register ISRCTN78640169.

Electrical stimulation and pelvic floor muscle training with biofeedback in patients with fecal incontinence: a cohort study of 281 patients

PURPOSE

Pelvic floor rehabilitation is an appealing treatment for patients with fecal incontinence but reported results vary. This study was designed to assess the outcome of pelvic floor rehabilitation in a large series of consecutive patients with fecal incontinence caused by different etiologies.

METHODS

A total of 281 patients (252 females) were included. Data about medical history, anal manometry, rectal capacity measurement, and endoanal sonography were collected. Subgroups of patients were defined by anal sphincter complex integrity, and nature and possible underlying causes of fecal incontinence. Subsequently patients were referred for pelvic floor rehabilitation, comprising nine sessions of electric stimulation and pelvic floor muscle training with biofeedback. Pelvic floor rehabilitation outcome was documented with Vaizey score, anal manometry, and rectal capacity measurement findings.

RESULTS

Vaizey score improved from baseline in 143 of 239 patients (60 percent), remained unchanged in 56 patients (23 percent), and deteriorated in 40 patients (17 percent). Mean Vaizey score reduced with 3.2 points (P < 0.001). A Vaizey score reduction of >or= 50 percent was observed in 32 patients (13 percent). Mean squeeze pressure (+5.1 mmHg; P = 0.04) and maximal tolerated volume (+11 ml; P = 0.01) improved from baseline. Resting pressure (P = 0.22), sensory threshold (P = 0.52), and urge sensation (P = 0.06) remained unchanged. Subgroup analyses did not show substantial differences in effects of pelvic floor rehabilitation between subgroups.

CONCLUSIONS

Pelvic floor rehabilitation leads overall to a modest improvement in severity of fecal incontinence, squeeze pressure, and maximal tolerated volume. Only in a few patients, a substantial improvement of the baseline Vaizey score was observed. Further studies are needed to identify patients who most likely will benefit from pelvic floor rehabilitation.

The current role of imaging techniques in faecal incontinence

Faecal incontinence is a common multifactorial disorder. Major causes of faecal incontinence are related to vaginal delivery and prior anorectal surgery. In addition to medical history and physical examination, several anorectal functional tests and imaging techniques can be used to assess the underlying pathophysiology and to guide treatment planning in faecal incontinent patients. Anorectal functional tests provide functional information, but the potential strength comes from combining test results. Imaging techniques, including defecography, endoanal sonography, and magnetic resonance (MR) imaging, provide structural information about the anorectal region with a direct clinical impact. The major role of imaging techniques in faecal incontinence is visualising the structural and functional integrity of the anal sphincter complex. Both two-dimensional endoanal sonography and endoanal MR imaging are accurate tools to depict anal sphincter defects. The major advantage of endoanal MR imaging is the accurate demonstration of external anal sphincter atrophy. Recent studies have suggested that external phased array MR imaging and three-dimensional endoanal sonography are also valuable tools in the diagnostic work up of faecal incontinence. Decisions about the preferred technique will mainly be determined by availability and local expertise. This article demonstrates the current role of tests, predominantly imaging tests, in the diagnostic work up of faecal incontinence.