Biofeedback vs. electrostimulation in the treatment of postdelivery anal incontinence: a randomized, clinical trial

Targeted Electromyographic Biofeedback With Endoanal Electrostimulation for Anal Incontinence

Purpose. Anal incontinence (AI) is a disabling condition with a variable response to conservative physical therapies. We assess the utility of combining electromyographic biofeedback with endoanal electrostimulation targeted to the weakest areas of the pelvic floor using the MAPLe^® probe (Multiple Array Probe Leiden Novuqare). Methods. Patients with AI unresponsive to conservative measures were assessed before and after treatment with anorectal manometry (ARM), electromyography (EMG), Wexner Continence Scoring, Visual Analog Scoring (VAS), FIQL and SF-12 quality of life determination. Results. Of 29 patients in the final analysis, there was an improvement in the mean Wexner continence score from 13.59 to 8.03 and a concomitant improvement in the reported VAS from 3.45 to 6.72. Both Wexner continence and VAS scores were maintained during follow-up. Maximum voluntary manometric contraction significantly improved from 91.76 mmHg to 110.33 mmHg with no changes in resting pressure. The EMG values ​​(μV) that significantly improved included the average and peak resistance, the average general voluntary contraction, and the average and peak voluntary contraction for both the external anal sphincter and the puborectalis. In the FIQL, behavior, depression and shame domains improved after treatment and during follow-up with lifestyle improvements detected at 6 and 12 months. Physical and mental components of the SF-12 improved at 6 and 12 months. Conclusions. Targeted electromyographic biofeedback and endoanal electrostimulation using MAPLe® probe in AI patients sustainably improves objective ARM and EMG parameters along with subjective reporting of continence severity, VAS, and quality of life.

Administration of an Anal Bulking Agent With Polyacrylate-Polyalcohol Copolymer Particles Versus Endoanal Electrical Stimulation With Biofeedback for the Management of Mild and Moderate Anal Incontinence: A Randomized Prospective Study

BACKGROUND

There are few treatment options for mild-to-moderate anal incontinence with isolated internal anal sphincter defects or anal incontinence without muscle damage. Less-invasive techniques are generally favored.

OBJECTIVE

To compare the results between the use of an anal bulking agent with polyacrylate-polyalcohol copolymer particles and endoanal electrical stimulation with biofeedback in patients with mild or moderate anal incontinence.

DESIGN

This was a prospective parallel-group, single-institution, randomized clinical trial.

SETTINGS

This study was conducted in an ambulatory setting at the Colorectal Physiology Service of the Hospital das Clinicas, Medical School, University of Sao Paulo.

PATIENTS

This study included patients who had anal incontinence for >6 months with isolated internal anal sphincter muscle damage or absence of anatomical defects in the anorectal sphincter complex.

INTERVENTIONS

Anal bulking agent and endoanal electrical stimulation with biofeedback.

MAIN OUTCOME MEASURES

The primary outcome measure was the Cleveland Clinic Florida Fecal Incontinence Score, and the secondary outcome measures included quality of life, recommended procedures, and anorectal manometry.

RESULTS

There were no significant between-group differences in mean age, sex, BMI, stool consistency, and Cleveland Clinic Florida Fecal Incontinence Score (p = 0.20) at baseline. After 12 months, the Cleveland Clinic Florida Fecal Incontinence Score was found to be significantly improved in patients treated with the bulking agent compared to those treated with electrical stimulation (mean, 6.2 vs 9.2; p = 0.002), though the anorectal manometry parameters did not change significantly. The mean anal Cleveland Clinic Florida Fecal Incontinence Score declined by 4.2 points in the bulking agent group compared to a decline of 0.8 in the electrical stimulation group (mean difference in decline: 3.4 points; 95% CI, 1.2-5.5). Quality-of life evaluation showed similar results between groups comparing baseline parameters with 12-month follow-up.

LIMITATIONS

The short follow-up period of 1 year, atypical method of biofeedback, and unmatched baseline in some of the quality-of-life scales between the 2 groups limited this study.

CONCLUSIONS

In patients with mild or moderate anal incontinence, the Cleveland Clinic Florida Fecal Incontinence Score significantly improved in the bulking agent with polyacrylate-polyalcohol copolymer group compared with the endoanal electrical stimulation with biofeedback group. See Video Abstract at http://links.lww.com/DCR/B938.

ADMINISTRACIN DE UN GEL ANAL CON PARTCULAS DE COPOLMERO DE POLIACRILATOPOLIALCOHOL VERSUS ESTIMULACIN ELCTRICA ENDOANAL CON EJERCICIOS ANALES BIOFEEDBACK PARA EL MANEJO DE LA INCONTINENCIA ANAL LEVE Y MODERADA UN ESTUDI PROSPECTIVO ALEATORIZADO

ANTECEDENTES:Hasta la fecha, existen pocas opciones de tratamiento para la incontinencia anal de leve a moderada con defectos aislados del esfínter anal interno o la incontinencia anal sin daño muscular. Por lo general, se prefieren técnicas menos invasivas.OBJETIVO:El objetivo fue comparar los resultados entre el uso de un gel intra-anal con partículas de copolímero de poliacrilato-polialcohol y la estimulación eléctrica endoanal con ejercicios anales en pacientes con incontinencia anal leve o moderada.DISEÑO:Este fue un ensayo clínico aleatorio prospectivo de grupos paralelos, de una institución, realizado en cuatro etapas: base, procedimientos, postratamiento temprano y tardío.AJUSTE:Este estudio se realizó en el ambulatorio de Fisiología Colorrectal del Servicio de Coloproctología del Hospital das Clínicas, Facultad de Medicina, Universidad de São Paulo.PACIENTES:Paciente con incontinencia anal con más de 6 meses, con daño muscular aislado del esfínter anal interno o ausencia de defectos anatómicos en el esfínter anorrectal.INTERVENCIONES:Las intervenciones incluyeron la inyección del gel intra-anal y estimulación eléctrica endoanal con ejercicios anales.PRINCIPALES MEDIDAS DE RESULTADO:Indice de incontinencia fecal (Cleveland Clinic Florida), Indice de calidad de vida, los procedimientos recomendados y la manometría anorrectal.RESULTADOS:No hubo diferencias significativas entre los grupos en cuanto a la edad media, el sexo, el índice de masa corporal, la consistencia de las heces y la puntuación de incontinencia fecal (p = 0,20) al inicio del estudio. Después de 12 meses, la puntuación de incontinencia fecal mejoró significativamente en los pacientes tratados con el el gel intra-anal (media = 6,2) en comparación con los tratados con estimulación eléctrica (media = 9,2; p = 0,002), aunque los parámetros de manometría anorrectal no mejoraron significativamente. La puntuación anal media de incontinencia fecal disminuyó 4,2 puntos en el grupo del Gel intra-anal en comparación con 0,8 en el grupo de estimulación eléctrica (diferencia media en la disminución: 3,4 puntos; IC del 95%: 1,2 a 5,5). La evaluación de la calidad de vida mostró resultados similares entre los grupos que compararon los parámetros iniciales con un seguimiento de 12 meses.LIMITACIONES:Breve período de seguimiento de un año, métodos diferentes de ejercicios anales y línea de base sin igual en algunas de las escalas de calidad de vida entre los dos grupos.CONCLUSIONES:En pacientes con incontinencia anal leve y moderada, la puntuación de incontinencia fecal mejoró significativamente en el grupo de gel intra-anal con copolímero de poliacrilato-polialcohol en comparación con la estimulación eléctrica endoanal. Consulte Video Resumen en http://links.lww.com/DCR/B938. (Traducción- Dr Leonardo Alfonso Bustamante-Lopez).

Physiotherapeutic Approaches to Treat Anal Incontinence in Women after Obstetric Trauma

Introduction Anal incontinence is defined as the loss of voluntary control of fecal matter or gases with a recurrence period longer than 3 months in individuals aged ≥ 4 years; it has a female predominance. Among the treatment modalities is pelvic physiotherapy, the second line of treatment, which promotes the reeducation, coordination, and strengthening of the muscles of the pelvic floor to enable patients to return to their regular activities of daily living.

Objective To perform a systematic review on the physiotherapeutic treatments used in women between the ages of 18 and 65 years with a diagnosis of anal incontinence.

Material and methods Clinical studies written in Portuguese, Spanish and English were searched on the the following databases: Science Direct, Medical Literature Analysis and Retrieval System Online (Medline) via PubMed, Physiotherapy Evidence Database (PEDro), Scientific Electronic Library Online (SciELO), and Scopus.

Results Of the 998 articles found, only 4 studies met the inclusion criteria of the present systematic review. The physiotherapeutic approaches to treat women with anal incontinence are biofeedback, Kegel exercises, electrostimulation, and training of the pelvic floor muscles. The average score on the PEDro scale was of 6.25, which indicates that the methodological quality was good.

Conclusion Although pelvic physiotherapy is effective to treat anal incontinence, it must be promoted through the performance of evidence-based scientific research.

Randomized controlled trial of home biofeedback therapy versus office biofeedback therapy for fecal incontinence

BACKGROUND

Biofeedback therapy is useful for treatment of fecal incontinence (FI), but is not widely available and labor intensive. We investigated if home biofeedback therapy (HBT) is non-inferior to office biofeedback therapy (OBT).

METHODS

Patients with FI (≥1 episode/week) were randomized to HBT or OBT for 6 weeks. HBT was performed daily using novel device that provided resistance training and electrical stimulation with voice-guided instructions. OBT consisted of six weekly sessions. Both methods involved anal strength, endurance, and coordination training. Primary outcome was change in weekly FI episodes. FI improvement was assessed with stool diaries, validated instruments (FISI, FISS, and ICIQ-B), and anorectal manometry using intention-to-treat analysis.

KEY RESULTS

Thirty (F/M = 26/4) FI patients (20 in HBT, 10 in OBT) participated. Weekly FI episodes decreased significantly after HBT (Δ ± 95% confidence interval: 4.7 ± 1.8, compared with baseline, p = 0.003) and OBT (3.7 ± 1.6, p = 0.0003) and HBT was non-inferior to OBT (p = 0.2). The FISI and FISS scores improved significantly in HBT group (p < 0.02). Bowel pattern, bowel control, and quality of life (QOL) domains (ICIQ-B) improved significantly in HBT arm (p < 0.023). Resting and maximum squeeze sphincter pressures significantly improved in both HBT and OBT groups and sustained squeeze pressure in HBT, without group differences.

CONCLUSIONS & INFERENCES

Home biofeedback therapy is non-inferior to OBT for FI treatment. Home biofeedback is safe, effective, improves QOL, and through increased access could facilitate improved management of FI.

Vaginal Electrical Stimulation for Postpartum Neuromuscular Recovery: A Randomized Clinical Trial

OBJECTIVE

The aim of this study was to compare 3-month postpartum anal incontinence symptoms in women who sustain obstetric anal sphincter injuries and begin immediate vaginal electrical stimulation versus sham therapy.

METHODS

In this double-blind randomized controlled trial, women who sustained obstetric anal sphincter injuries were randomized to receive self-administered vaginal electrical stimulation using a commercial device or sham therapy with an identical device. Anal incontinence symptom severity was assessed at 1 week (baseline) and again at 13 weeks postpartum using the Fecal Incontinence Severity Index. The primary outcome was anal incontinence symptom severity measured by the total Fecal Incontinence Severity Index score at 13 weeks postpartum.

RESULTS

Between February 2016 and September 2018, 48 women completed a 13-week follow-up. At 13 weeks postpartum, median Fecal Incontinence Severity Index scores were higher (more severe) in the vaginal electrical stimulation group (12; interquartile range, 0-23) than in the sham group (4; interquartile range, 0-10) (P = 0.04). Unlike the vaginal electrical stimulation group, the improvement in Fecal Incontinence Severity Index scores in the sham group (vaginal electrical stimulation: 12 [interquartile range, 8-22] to 12 [interquartile range, 0-23] [P = 0.12] vs sham: 12 [interquartile range, 6-18] to 4.0 [interquartile range, 0-11] [P < 0.001]) met the threshold for clinical significance based on the minimum important difference of the Fecal Incontinence Severity Index.

CONCLUSION

At 13 weeks postpartum, women who underwent postpartum vaginal electrical stimulation reported more anal incontinence symptoms compared with those receiving sham therapy. Vaginal electrical stimulation after obstetric anal sphincter injury was not beneficial in reducing anal incontinence symptoms and may impede recovery.

Physiotherapy for Prevention and Treatment of Fecal Incontinence in Women-Systematic Review of Methods

Fecal incontinence (FI) affects approximately 0.25-6% of the population, both men and women. The most common causes of FI are damage to/weakness of the anal sphincter muscle and/or pelvic floor muscles, as well as neurological changes in the central or peripheral nervous system. The purpose of this study is to report the results of a systematic review of the possibilities and effectiveness of physiotherapy techniques for the prevention and treatment of FI in women. For this purpose, the PubMed, Embase, and Web of Science databases were searched for 2000-2020. A total of 22 publications qualified for detailed analysis. The studies showed that biofeedback (BF), anal sphincter muscle exercises, pelvic floor muscle training (PFMT), and electrostimulation (ES) are effective in relieving FI symptoms, as reflected in the International Continence Society recommendations (BF: level A; PFMT and ES: level B). Research has confirmed that physiotherapy, by improving muscle strength, endurance, and anal sensation, is beneficial in the prevention of FI, both as an independent method of conservative treatment or in pre/post-surgery treatment. Moreover, it can significantly improve the quality of life of patients. In conclusion, physiotherapy (in particular, BF, PFMT, or ES, as effective methods) should be one of the key elements in the comprehensive therapy of patients with FI.

PREDICTORS OF UNSUCCESSFUL OF TREATMENT FOR FECAL INCONTINENCE BIOFEEDBACK FOR FECAL INCONTINENCE IN FEMALE

BACKGROUND

Biofeedback is an effective method of treatment for fecal incontinence but there is controversy regarding factors that may be correlated with its effectiveness.

OBJECTIVE

To evaluate the efficacy of biofeedback in the treatment of fecal incontinence, identifying the predictive factors for unsuccessful treatment.

METHODS

Consecutive female patients who had fecal incontinence and were treated with a full course of biofeedback were screened. The symptoms were evaluated using Cleveland Clinic incontinence (CCF) score before and six months after the completion of therapy. Patients had a satisfactory clinical response to biofeedback if the CCF score had decreased by more than 50% at six months (GI) and an unsatisfactory response if the CCF score did not decrease or if the score decreased by <50% (GII). The groups were compared with regard to age, score, anal resting and squeeze pressures and sustained squeeze pressure by manometry, history of vaginal delivery, number of vaginal deliveries, menopause, hysterectomy, and previous anorectal surgery.

RESULTS

Of 124 women were included, 70 (56%) in GI and 54 (44%) in GII. The median CCF score decreased significantly from 10 to 5 (P=0.00). FI scores were higher in GII. Patients from GII had more previous vaginal deliveries and previous surgeries. The mean sustained squeeze pressure was higher in GI. Patients from GI and GII had similar ages, number of vaginal deliveries, menopause, hysterectomy, anal pressures, and sphincter defects. The median sustained squeeze pressure increased significantly before and after biofeedback in GI.

CONCLUSION

Biofeedback therapy shows effective treatment with 50% reductions in FI score in half of patients. Factors associated with unsuccessful outcome include FI score ≥10, previous vaginal delivery, previous anorectal and/or colorectal surgery, and reduced mean sustained squeeze pressure.

A Practical Guide to Biofeedback Therapy for Pelvic Floor Disorders

PURPOSE OF REVIEW

Biofeedback therapy (BFT) is effective for managing pelvic floor disorders (i.e., defecatory disorders and fecal incontinence). However, even in controlled clinical trials, only approximately 60% of patients with defecatory disorders experienced long-term improvement. The review serves to update practitioners on recent advances and to identify practical obstacles to providing biofeedback therapy.

RECENT FINDINGS

The efficacy and safety of biofeedback therapy have been evaluated in defecatory disorders, fecal incontinence, and levator ani syndrome. Recent studies looked at outcomes in specific patient sub-populations and predictors of a response to biofeedback therapy. Biofeedback therapy is effective for managing defecatory disorders, fecal incontinence, and levator ani syndrome. Patients who have a lower bowel satisfaction score and use digital maneuvers fare better. Biofeedback therapy is recommended for patients with fecal incontinence who do not respond to conservative management. A subset of patients with levator ani syndrome who have dyssynergic defecation are more likely to respond to biofeedback therapy.

A systematic review and network meta-analysis comparing treatments for faecal incontinence

BACKGROUND

Although numerous treatments exist for fecal incontinence (FI), no consensus exists on the best treatment strategy. The aim was to review the literature and to compare the clinical outcomes and effectiveness of treatments available for FI.

MATERIALS AND METHOD

A systematic literature review was performed, from inception to May 2018, of the following databases: MEDLINE, EMBASE, Science Citation Index Expanded, Cochrane Library. The search terms used were "faecal incontinence" and "treatment". Only randomized controlled trials (RCTs) comparing treatments for FI were considered. A Bayesian network meta-analysis was performed using the Markov chain Monte Carlo method.

RESULT

Forty-seven RCTs were included comparing 37 treatments and reporting on 3748 participants. No treatment ranked best or worst with high probability for any outcome of interest. No significant difference was identified between treatments for frequency of FI per week, or in changing the resting pressure, maximum resting pressure, squeeze pressure, and maximum squeeze pressure. Radiofrequency resulted in more adverse events compared to placebo. Sacral nerve stimulation (SNS) and zinc-aluminium improved the fecal incontinence quality of life questionnaire (FIQL) lifestyle, coping, and embarrassment domains compared to placebo. Transcutaneous posterior tibial nerve stimulation (TPTNS) improved the FIQL embarrassment domain compared to placebo. Autologous myoblasts and zinc-aluminium improved the FIQL depression domain compared to placebo. SNS, artificial bowel sphincter (ABS), and zinc-aluminium significantly improved incontinence scores compared to placebo. Injection of non-animal stabilized hyaluronic acid/dextranomer (NASHA/Dx) resulted in more patients with ≥50% reduction in FI episodes compared to placebo.

CONCLUSION

SNS, ABS, TPTNS, NASHA/Dx, zinc-aluminium, and autologous myoblasts resulted in isolated improvements in specific outcomes of interest. No difference was identified in incontinence episodes, no treatment ranked best persistently or persistently improved outcomes, and many included treatments did not significantly benefit patients compared to placebo. Large multicentre RCTs with long-term follow-up and standardized inclusion criteria and outcome measures are needed.

A systematic review of the literature reporting on randomised controlled trials comparing treatments for faecal incontinence in adults

AIM

To perform a review of the literature reporting on randomised controlled trials (RCTs) comparing treatments for faecal incontinence (FI) in adults.

METHODS

A literature search of MEDLINE, Embase, Science Citation Index Expanded and Cochrane was performed in order to identify RCTs reporting on treatments for FI.

RESULTS

The review included 60 RCTs reporting on 4838 patients with a mean age ranging from 36.8 to 88 years. From the included RCTs, 32 did not identify a significant difference between the treatments compared. Contradictory results were identified in RCTs comparing percutaneous posterior tibial nerve stimulation and transcutaneous tibial nerve stimulation versus sham stimulation, biofeedback-pelvic floor muscle training (BF-PFMT) versus PFMT, and between bulking agents such as PTQ^TM versus Durasphere^®. In two separate RCTs, combination treatment of amplitude-modulated medium frequency stimulation and electromyography-biofeedback (EMG-BF), was noted to be superior to EMG-BF and low-frequency electrical stimulation alone. Combination of non-surgical treatments such as BF with sphincteroplasty significantly improved continence scores compared to sphincteroplasty alone. Surgical treatments were associated with higher rates of serious adverse events compared to non-surgical interventions.

CONCLUSIONS

The current evidence has not identified significant differences between treatments for FI, and where differences were identified, the results were contradictory between RCTs.

Implantation of autologous muscle-derived stem cells in treatment of fecal incontinence: results of an experimental pilot study

Background

The aim of this study is to present results of the implantation of autologous myoblasts into the external anal sphincter (EAS) in ten patients with fecal incontinence.

Methods

After anatomical and functional assessment of the patients’ EAS, a vastus lateralis muscle open biopsy was performed. Stem cells were extracted from the biopsy specimens and cultured in vitro. Cell suspensions were then administered to the EAS. Patients were scheduled for follow-up visits in 6-week intervals. Total follow-up was 12 months.

Results

All biopsy and cell implantation procedures were performed without complications. Nine of the patients completed a full 12-month follow-up. There was subjective improvement in six patients (66.7 %). In manometric examinations 18 weeks after implantation, squeeze anal pressures and high-pressure zone length increased in all patients, with particularly significant sphincter function recovery in five patients (55.6 %). Electromyographic (EMG) examination showed an increase in signal amplitude in all patients, detecting elevated numbers of propagating action potentials. Twelve months after implantation two patients experienced deterioration of continence, which was also reflected in the deterioration of manometric and EMG parameters. The remaining four patients (44.4 %) still described their continence as better than before implantation and retained satisfactory functional examination parameters.

Conclusions

Implantation of autologous myoblasts gives good short-term results not only in a subjective assessment, but also in objective functional tests. It seems that this promising technology can improve the quality of life of patients with fecal incontinence, but further study is required to achieve better and more persistent results.

ANMS-ESNM position paper and consensus guidelines on biofeedback therapy for anorectal disorders

BACKGROUND

Anorectal disorders such as dyssynergic defecation, fecal incontinence, levator ani syndrome, and solitary rectal ulcer syndrome are common, and affect both the adult and pediatric populations. Although they are treated with several treatment approaches, over the last two decades, biofeedback therapy using visual and verbal feedback techniques has emerged as an useful option. Because it is safe, it is commonly recommended. However, the clinical efficacy of biofeedback therapy in adults and children is not clearly known, and there is a lack of critical appraisal of the techniques used and the outcomes of biofeedback therapy for these disorders.

PURPOSE

The American Neurogastroenterology and Motility Society and the European Society of Neurogastroenterology and Motility convened a task force to examine the indications, study performance characteristics, methodologies used, and the efficacy of biofeedback therapy, and to provide evidence-based recommendations. Based on the strength of evidence, biofeedback therapy is recommended for the short-term and long-term treatment of constipation with dyssynergic defecation (Level I, Grade A), and for the treatment of fecal incontinence (Level II, Grade B). Biofeedback therapy may be useful in the short-term treatment of Levator Ani Syndrome with dyssynergic defecation (Level II, Grade B), and solitary rectal ulcer syndrome with dyssynergic defecation (Level III, Grade C), but the evidence is fair. Evidence does not support the use of biofeedback for the treatment of childhood constipation (Level 1, Grade D).

Improvement of fecal incontinence and quality of life by electrical stimulation and biofeedback for patients with low rectal cancer after intersphincteric resection

OBJECTIVE

To assess the efficacy and benefits of pelvic rehabilitation programs in terms of functional outcomes and quality of life for patients with fecal incontinence and defecation disorders after rectal cancer surgery.

DESIGN

Prospective, observational study.

SETTING

University hospital physiotherapy clinics.

PARTICIPANTS

Patients (N=32) who experienced fecal incontinence after sphincter-saving surgery with the intersphincteric resection (ISR) technique and could follow and cooperate with the treatment schedule were included in the present study.

INTERVENTIONS

Pelvic rehabilitation programs included electrical stimulation (ES) and biofeedback (BF).

MAIN OUTCOME MEASURES

Functional results, Wexner score, and anorectal manometry were used to assess the clinical outcomes of rehabilitation treatment.

RESULTS

Maximum squeeze pressure improved after rehabilitation training (P=.014). There were no statistical differences in resting pressure, resting muscle electromyography, and maximum squeeze electromyography (P=.061, P=.76, and P=.99, respectively). The mean stool frequency was 18.8 per 24 hours before the pelvic intervention program and 7.8 per 24 hours after ES and BF training (P<.001). Of the 32 patients, 27 required antidiarrheal medications before treatment, and after completion of the training, only 9 patients still needed antidiarrheal medications (P<.001). Significant improvements were observed in the Wexner score (17.74 vs 12.93; P<.001).

CONCLUSIONS

Our data show that ES and BF are effective in the treatment of fecal incontinence, leading to improvement of quality of life for patients with low rectal cancer after ISR.

Pelvic floor rehabilitation in the treatment of fecal incontinence

Fecal incontinence (FI) is a prevalent problem that can drastically affect quality of life. Pelvic floor rehabilitation is an important first-line treatment for patients with FI, and many published case reports and a small number of randomized controlled trials (RCTs) provide limited evidence for its efficacy. Pelvic floor rehabilitation approaches to the treatment of FI include pelvic floor muscle training, biofeedback, and volumetric training with rectal balloon catheters. Various forms of external electrical stimulation have also been described and may be of added benefit. Behavioral bowel retraining is an important part of a good rehabilitative approach as well. Pelvic floor rehabilitation treatment for FI is thought to be effective and safe, with reported success rates in a majority of studies at 50 to 80%. Many more high-quality RCTs are needed to define optimal treatment protocols.

Current management of fecal incontinence: Choosing amongst treatment options to optimize outcomes

The severity of fecal incontinence widely varies and can have dramatic devastating impacts on a person’s life. Fecal incontinence is common, though it is often under-reported by patients. In addition to standard treatment options, new treatments have been developed during the past decade to attempt to effectively treat fecal incontinence with minimal morbidity. Non-operative treatments include dietary modifications, medications, and biofeedback therapy. Currently used surgical treatments include repair (sphincteroplasty), stimulation (sacral nerve stimulation or posterior tibial nerve stimulation), replacement (artificial bowel sphincter or muscle transposition) and diversion (stoma formation). Newer augmentation treatments such as radiofrequency energy delivery and injectable materials, are minimally invasive tools that may be good options before proceeding to surgery in some patients with mild fecal incontinence. In general, more invasive surgical treatments are now reserved for moderate to severe fecal incontinence. Functional and quality of life related outcomes, as well as potential complications of the treatment must be considered and the treatment of fecal incontinence must be individualized to the patient. General indications, techniques, and outcomes profiles for the various treatments of fecal incontinence are discussed in detail. Choosing the most effective treatment for the individual patient is essential to achieve optimal outcomes in the treatment of fecal incontinence.

Electrical stimulation and biofeedback for the treatment of fecal incontinence: a systematic review

PURPOSE

This systematic review determines the best known form of biofeedback (BF) and/or electrical stimulation (ES) for the treatment of fecal incontinence in adults and rates the quality of evidence using the Grades of Recommendation, Assessment, Development, and Evaluation. Attention is given to type, strength, and application mode of the current for ES and to safety.

METHODS

Methods followed the Cochrane Handbook. Randomized controlled trials were included. Studies were searched in The Cochrane Library, MEDLINE, and EMBASE (registration number (PROSPERO): CRD42011001334).

RESULTS

BF and/or ES were studied in 13 randomized parallel-group trials. In 12 trials, at least one therapy group received BF alone and/or in combination with ES, while ES alone was evaluated in seven trials. Three (four) trials were rated as of high (moderate) quality. Average current strength was reported in three of seven studies investigating ES; only two studies reached the therapeutic window. No trial showed superiority of control, or of BF alone or of ES alone when compared with BF + ES. Superiority of BF + ES over any monotherapy was demonstrated in several trials. Amplitude-modulated medium-frequency (AM-MF) stimulation, also termed pre-modulated interferential stimulation, combined with BF was superior to both low-frequency ES and BF alone, and 50 % of the patients were continent after 6 months of treatment. Effects increased with treatment duration. Safety reporting was bad, and there are safety issues with some forms of low-frequency ES.

CONCLUSIONS

There is sufficient evidence for the efficacy of BF plus ES combined in treating fecal incontinence. AM-MF plus BF seems to be the most effective and safe treatment.

KEY MESSAGES

• The higher the quality of the randomized trial the more likely was a significant difference between treatment groups. • Two times more patients became continent when biofeedback was used instead of a control, such as pelvic floor exercises. • Two times more patients became continent when biofeedback plus electrical stimulation was used instead of biofeedback only. • Low-frequency electrical stimulation can have adverse device effects, and this is in contrast to amplitude-modulated medium-frequency electrical stimulation. • There is high quality evidence that amplitude-modulated medium-frequency electrical stimulation plus electromyography biofeedback is the best second-line treatment for fecal incontinence.

Biofeedback and/or sphincter exercises for the treatment of faecal incontinence in adults

BACKGROUND

Faecal incontinence is a particularly embarrassing and distressing condition with significant medical, social and economic implications. Anal sphincter exercises (pelvic floor muscle training) and biofeedback therapy have been used to treat the symptoms of people with faecal incontinence. However, standards of treatment are still lacking and the magnitude of alleged benefits has yet to be established.

OBJECTIVES

To determine the effects of biofeedback and/or anal sphincter exercises/pelvic floor muscle training for the treatment of faecal incontinence in adults.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 24 January 2012) which contains trials from searching CENTRAL, MEDLINE and handsearching of conference proceedings; and the reference lists of relevant articles.

SELECTION CRITERIA

All randomised or quasi-randomised trials evaluating biofeedback and/or anal sphincter exercises in adults with faecal incontinence.

DATA COLLECTION AND ANALYSIS

Two review authors assessed the risk of bias of eligible trials and two review authors independently extracted data from the included trials. A wide range of outcome measures were considered.

MAIN RESULTS

Twenty one eligible studies were identified with a total of 1525 participants. About half of the trials had low risk of bias for randomisation and allocation concealment.One small trial showed that biofeedback plus exercises was better than exercises alone (RR for failing to achieve full continence 0.70, 95% CI 0.52 to 0.94).One small trial showed that adding biofeedback to electrical stimulation was better than electrical stimulation alone (RR for failing to achieve full continence 0.47, 95% CI 0.33 to 0.65).The combined data of two trials showed that the number of people failing to achieve full continence was significantly lower when electrical stimulation was added to biofeedback compared against biofeedback alone (RR 0.60, 95% CI 0.46 to 0.78).Sacral nerve stimulation was better than conservative management which included biofeedback and PFMT (at 12 months the incontinence episodes were significantly fewer with sacral nerve stimulation (MD 6.30, 95% CI 2.26 to 10.34).There was not enough evidence as to whether there was a difference in outcome between any method of biofeedback or exercises. There are suggestions that rectal volume discrimination training improves continence more than sham training. Further conclusions are not warranted from the available data.

AUTHORS' CONCLUSIONS

The limited number of identified trials together with methodological weaknesses of many do not allow a definitive assessment of the role of anal sphincter exercises and biofeedback therapy in the management of people with faecal incontinence. We found some evidence that biofeedback and electrical stimulation may enhance the outcome of treatment compared to electrical stimulation alone or exercises alone. Exercises appear to be less effective than an implanted sacral nerve stimulator. While there is a suggestion that some elements of biofeedback therapy and sphincter exercises may have a therapeutic effect, this is not certain. Larger well-designed trials are needed to enable safe conclusions.

Biofeedback for the treatment of female pelvic floor muscle dysfunction: a systematic review and meta-analysis

Biofeedback (BF) has been widely used in the treatment of pelvic floor dysfunctions, mainly by promoting patient learning about muscle contraction with no side effects. However, its effectiveness remains poorly understood with some studies suggesting that BF offers no advantage over the isolated pelvic floor muscle training (PFMT). The main objective of this study was to systematically review available randomized controlled trials assessing the effectiveness of BF in female pelvic floor dysfunction treatment. Trials were electronically searched and rated for quality by use of the PEDro scale (values of 0-10). Randomized controlled trials assessing the training of pelvic floor muscle (PFM) using BF in women with PFM dysfunction were selected. Outcomes were converted to a scale ranging from 0 to 100. Trials were pooled with software used to prepare and update Cochrane reviews. Results are presented as weighted mean differences with 95 % confidence intervals (CI). Twenty-two trials with 1,469 patients that analyzed BF in the treatment of urinary, anorectal, and/or sexual dysfunctions were included. PFMT alone led to a superior but not significant difference in the function of PFM when compared to PFMT with BF, by using vaginal measurement in the short and intermediate term: 9.89 (95 % CI -5.05 to 24.83) and 15.03 (95 % CI -9.71 to 39.78), respectively. We found a few and nonhomogeneous studies addressing anorectal and sexual function, which do not provide the cure rate calculations. Limitations of this review are the low quality and heterogeneity of the studies, involving the usage of distinct protocols of interventions, and various and different outcome measures. The results of this systematic review suggest that PFMT with BF is not more effective than other conservative treatments for female PFM dysfunction.

Triple-target treatment versus low-frequency electrostimulation for anal incontinence: a randomized, controlled trial

BACKGROUND

In the nonsurgical treatment of anal incontinence, the combination of amplitude-modulated medium-frequency stimulation and electromyographic biofeedback (EMG-BF), known as triple-target treatment (3T), is superior to EMG-BF alone. The aim of this trial is to compare 3T with the standard treatment, low-frequency stimulation (LFS).

METHODS

80 patients with anal incontinence of Grade I or higher who presented to physicians or centers specialized in coloproctology were enrolled in this multicenter randomized trial with blinded observer. The trial had an open parallel-group design. Randomization was performed centrally by telephone. The primary endpoint was the Cleveland Clinic Score (CCS) after self-training at home with either 3T or LFS in two 20-minute sessions per day for 6 months. The secondary endpoints included the proportion of patients regaining continence, and the patients' quality of life (QoL). On completion of the trial as planned, the results were evaluated with an intention-to-treat analysis.

STUDY REGISTRATION

DRKS00000138 (http://register.germanctr.de).

RESULTS

39 patients were randomized to 3T, and 41 to LFS. After 6 months of treatment, the CCS (mean ± standard deviation) was 3.1 ± 4.2 in the 3T group and 9.6 ± 3.9 in the LFS group. The median improvement in the CCS at 6 months compared to baseline was 7 points greater in the 3T group than in the LFS group (95% CI: 5-9, p<0.001). Anal continence was regained by 54% of the 3T patients, but none of the LFS patients (95% CI for the difference: 37.18% - 69.91%, p<0.001). QoL scores were higher in all dimensions in the 3T group than in the LFS group. No major adverse effects occurred in either group.

CONCLUSION

3T is superior to LFS in the treatment of anal incontinence. The available evidence suggests that the success of 3T is based on the combined effect of biofeedback and medium-frequency stimulation. LFS of the type applied in this trial has no effect. 3T should be used in routine clinical practice instead of LFS.

Biofeedback for fecal incontinence: a randomized study comparing exercise regimens

BACKGROUND

Fecal incontinence affects up to 11% of Australian community-dwelling adults and 72% of nursing home residents. Biofeedback is a recommended conservative therapy when medication and pelvic floor exercises have failed to improve patient outcomes.

OBJECTIVE

This study aimed to investigate the impact of a new exercise regimen on the severity of fecal incontinence and the quality of life of participants.

DESIGN

This was a randomized clinical study.

SETTINGS

This study was conducted at the Anorectal Physiology Clinic, Townsville Hospital, Queensland, Australia.

PATIENTS

Seventy-two participants (19 male), with a mean age of 62.1 years, attended 5 clinic sessions: 4 weekly sessions followed by 4 weeks of home practice and a follow-up assessment session. A postal survey was conducted 2 years later.

INTERVENTION

Thirty-seven patients (12 male) were randomly assigned to the standard clinical protocol (sustained submaximal anal and pelvic floor exercises) and 35 patients (7 male) were randomly assigned to the alternative group (rapid squeeze plus sustained submaximal exercises).

MAIN OUTCOME MEASURES

The main outcomes were measured by use of the Cleveland Clinic Florida Fecal Incontinence score and the Fecal Incontinence Quality of Life Scale survey tool.

RESULTS

No significant differences were found between the 2 exercise groups at the beginning or at the end of the study or as a result of treatment in objective, quality-of-life, or fecal incontinence severity measures. Sixty-nine participants completed treatment. The severity of fecal incontinence decreased significantly (11.5/20 to 5.0/20, P < .001). Eighty-six percent (59/69) of participants reported improved continence. Quality of life significantly improved for all participants (P < .001). Results were sustained 2 years later. Patients who practiced at least the prescribed number of exercises had better outcomes than those who practiced fewer exercises.

LIMITATIONS

This study was limited because it involved a heterogeneous sample, it was based on subjective reporting of exercise performance, and loss to follow-up occurred because of the highly mobile population.

CONCLUSIONS

Patients attending this biofeedback program attained significant improvement in the severity of their fecal incontinence and in their quality of life. Although introduction of rapid muscle squeezes had little impact on fecal incontinence severity or patient quality of life, patient exercise compliance at prescribed or greater levels did.

Efficacy of dextranomer in stabilised hyaluronic acid for treatment of faecal incontinence: a randomised, sham-controlled trial

BACKGROUND

Injection of a bulking agent in the anal canal is an increasingly used treatment for faecal incontinence, but efficacy has not been shown in a controlled trial. We aimed to assess the efficacy of injection of dextranomer in stabilised hyaluronic acid (NASHA Dx) for treatment of faecal incontinence.

METHODS

In this randomised, double-blind, sham-controlled trial, patients aged 18-75 years from centres in USA and Europe were randomly assigned (2:1) to receive either transanal submucosal injections of NASHA Dx or sham injections. Randomisation was stratified by sex and region in blocks of six, and managed with a computer generated, real-time, web-based system. Patients and investigators were masked to assignment for 6 months when the effect on severity of faecal incontinence and quality of life was assessed with a 2-week diary and clinical assessments. The primary endpoint was response to treatment based on the number of incontinence episodes. A response to treatment was defined as a reduction in number of episodes by 50% or more. Patients in the active treatment group are still being followed up. This trial was registered with ClinicalTrials.gov, number NCT00605826.

FINDINGS

278 patients were screened for inclusion, of whom 206 were randomised assigned to receive NASHA Dx (n=136) or sham treatment (n=70). 71 patients who received NASHA Dx (52%) had a 50% or more reduction in the number of incontinence episode, compared with 22 patients who received sham treatment (31%; odds ratio 2·36, 95% CI 1·24-4·47, p=0·0089). We recorded 128 treatment-related adverse events, of which two were serious (1 rectal abscess and 1 prostatic abscess).

INTERPRETATION

Anal injection of NASHA Dx is an effective treatment for faecal incontinence. A refinement of selection criteria for patients, optimum injected dose, ideal site of injection, and long-term results might further increase the acceptance of this minimally invasive treatment.

FUNDING

Q-Med AB.

Biofeedback therapy in fecal incontinence and constipation

We examine the collected evidence for efficacy of biofeedback therapy (BFT) in incontinence and constipation by means of meta-analysis of randomized controlled trials. PubMed search was performed to identify treatment trials that match quality criteria (adequate control groups, randomization). They were entered into meta-analyses using fixed effect models and computing odds ratio (OR) and 95% confidence interval (CI) of treatment effects. For constipation, eight BFT trials were identified. In four trials, electromyographic (EMG) BFT was compared to non-BFT treatments (laxatives, placebo, sham training and botox injection), while in the remaining four studies EMG BFT was compared to other BFT (balloon pressure, verbal feedback) modes. Meta-analyses revealed superiority of BFT to non-BFT (OR: 3.657; 95% CI: 2.127-6.290, P < 0.001) but equal efficacy of EMG BFT to other BF applications (OR: 1.436; CI: 0.692-3.089; P = 0.319). For fecal incontinence, a total of 11 trials were identified, of which six compared BFT to other treatment options (sensory training, pelvic floor exercise and electrical stimulation) and five compared one BFT option to other modalities of BFT. BFT was equal effective than non-BFT therapy (OR: 1.189, CI: 0.689-2.051, P = 0.535). No difference was found when various modes BFT were compared (OR: 1.278, CI: 0.736-2.220, P = 0.384). Included trials showed a substantial lack of quality and harmonization, e.g. variable endpoints and missing psychological assessment across studies. BFT for pelvic floor dyssynergia shows substantial specific therapeutic effect while BFT for incontinence is still lacking evidence for efficacy. However, in both conditions the mode of BFT seems to play a minor role.

Common anorectal disorders: diagnosis and treatment

Anorectal disorders affect men and women of all ages. Their management is not limited to the evaluation and treatment of hemorrhoids. Rather, a spectrum of anorectal disorders ranges from benign and irritating (pruritus ani) to potentially life-threatening (anorectal cancer). Symptoms are nonspecific, which can make the evaluation of patients difficult. In addition, treatment can be frustrating because clinicians are hamstrung by a lack of well-designed, prospective, clinical trials. Some of the most common anorectal disorders include fecal incontinence, pelvic floor dyssynergia, anal fissures, pruritus ani, proctalgia fugax, and solitary rectal ulcer syndrome. This article provides an update on the evaluation and treatment of common anorectal disorders.

Fecal incontinence and biofeedback therapy

Biofeedback as delivered in most clinical settings in Western medicine has been consistently reported to improve symptoms of fecal incontinence. Closer scrutiny of the elements of the intervention and controlled studies, however, have consistently failed to find any benefit of the biofeedback element of this complex package of care; nor has any superiority been found for one modality over another. There is a need for further well-designed and adequately powered randomized controlled trials. Meanwhile, there can be little doubt that conservative interventions improve many patients with fecal incontinence to the point where most report satisfaction with treatment and do not wish to consider more invasive options, such as surgery.