Peristeen Transanal Irrigation System to Manage Bowel Dysfunction: A NICE Medical Technology Guidance

Baiona's Consensus Statement for Fecal Incontinence. Spanish Association of Coloproctology

Faecal incontinence (FI) is a major health problem, both for individuals and for health systems. It is obvious that, for all these reasons, there is widespread concern for healing it or, at least, reducing as far as possible its numerous undesirable effects, in addition to the high costs it entails. There are different criteria for the diagnostic tests to be carried out and the same applies to the most appropriate treatment, among the numerous options that have proliferated in recent years, not always based on rigorous scientific evidence. For this reason, the Spanish Association of Coloproctology (AECP) proposed to draw up a consensus to serve as a guide for all health professionals interested in the problem, aware, however, that the therapeutic decision must be taken on an individual basis: patient characteristics/experience of the care team. For its development it was adopted the Nominal Group Technique methodology. The Levels of Evidence and Grades of Recommendation were established according to the criteria of the Oxford Centre for Evidence-Based Medicine. In addition, expert recommendations were added briefly to each of the items analysed.

The urologist's role in bowel management of adult spina bifida: a narrative review

Background and Objective

Urologists are central to the coordinated care of patients with spina bifida (SB), and efforts to optimize bladder management and protection of the upper tracts are well established. However, the urologist's role in treating this population often extends to the management of bowel dysfunction which may be less defined. The methods available to the urologist for bowel management range from lifestyle modifications to medical and surgical therapy, with many patients requiring combinations of multiple strategies to combat conflicting symptoms of constipation and fecal incontinence (FI). This narrative review aims to compile a detailed algorithm of management options, for the practicing urologist to more confidently address this important facet of care.

Methods

A detailed review was conducted using PubMed and Google Scholar databases to assess the contemporary literature surrounding neurogenic bowel dysfunction in adult SB. Articles published in English between 1990 and 2023 were considered.

Key Content and Findings

This review presents and investigates a schema of increasingly definitive and invasive treatments for bowel dysfunction including lifestyle adaptations, pharmacological treatment, transanal irrigation (TAI), sacral neuromodulation (SNM), antegrade continence procedures, and bowel diversion. TAI and medical bowel care are beneficial in postponing or avoiding more invasive surgical interventions. Should conservative measures prove ineffective, surgical management provides the most definitive bowel control.

Conclusions

Symptoms of constipation and FI that result from neurogenic bowel are best managed with an individualized approach guided by the general treatment algorithm presented in this review. Educated on the numerous appropriate options, patients will often trial methods before proceeding with more invasive treatments. Additional work is required to further evaluate management options specific to the SB populations, especially in more contemporary and largely experimental treatment modalities such as SNM.

Strategies used for childhood chronic functional constipation: the SUCCESS evidence synthesis

Background

Up to 30% of children have constipation at some stage in their life. Although often short-lived, in one-third of children it progresses to chronic functional constipation, potentially with overflow incontinence. Optimal management strategies remain unclear.

Objective

To determine the most effective interventions, and combinations and sequences of interventions, for childhood chronic functional constipation, and understand how they can best be implemented.

Methods

Key stakeholders, comprising two parents of children with chronic functional constipation, two adults who experienced childhood chronic functional constipation and four health professional/continence experts, contributed throughout the research. We conducted pragmatic mixed-method reviews. For all reviews, included studies focused on any interventions/strategies, delivered in any setting, to improve any outcomes in children (0-18 years) with a clinical diagnosis of chronic functional constipation (excluding studies of diagnosis/assessment) included. Dual reviewers applied inclusion criteria and assessed risk of bias. One reviewer extracted data, checked by a second reviewer. Scoping review: We systematically searched electronic databases (including Medical Literature Analysis and Retrieval System Online, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature) (January 2011 to March 2020) and grey literature, including studies (any design) reporting any intervention/strategy. Data were coded, tabulated and mapped. Research quality was not evaluated. Systematic reviews of the evidence of effectiveness: For each different intervention, we included existing systematic reviews judged to be low risk of bias (using the Risk of Bias Assessment Tool for Systematic Reviews), updating any meta-analyses with new randomised controlled trials. Where there was no existing low risk of bias systematic reviews, we included randomised controlled trials and other primary studies. The risk of bias was judged using design-specific tools. Evidence was synthesised narratively, and a process of considered judgement was used to judge certainty in the evidence as high, moderate, low, very low or insufficient evidence. Economic synthesis: Included studies (any design, English-language) detailed intervention-related costs. Studies were categorised as cost-consequence, cost-effectiveness, cost-utility or cost-benefit, and reporting quality evaluated using the consensus health economic criteria checklist. Systematic review of implementation factors: Included studies reported data relating to implementation barriers or facilitators. Using a best-fit framework synthesis approach, factors were synthesised around the consolidated framework for implementation research domains.

Results

Stakeholders prioritised outcomes, developed a model which informed evidence synthesis and identified evidence gaps.

Scoping review

651 studies, including 190 randomised controlled trials and 236 primary studies, conservatively reported 48 interventions/intervention combinations.

Effectiveness systematic reviews

studies explored service delivery models (n = 15); interventions delivered by families/carers (n = 32), wider children's workforce (n = 21), continence teams (n = 31) and specialist consultant-led teams (n = 42); complementary therapies (n = 15); and psychosocial interventions (n = 4). One intervention (probiotics) had moderate-quality evidence; all others had low to very-low-quality evidence. Thirty-one studies reported evidence relating to cost or resource use; data were insufficient to support generalisable conclusions. One hundred and six studies described implementation barriers and facilitators.

Conclusions

Management of childhood chronic functional constipation is complex. The available evidence remains limited, with small, poorly conducted and reported studies. Many evidence gaps were identified. Treatment recommendations within current clinical guidelines remain largely unchanged, but there is a need for research to move away from considering effectiveness of single interventions. Clinical care and future studies must consider the individual characteristics of children.

Study registration

This study is registered as PROSPERO CRD42019159008.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 128470) and is published in full in Health Technology Assessment; Vol. 28, No. 5. See the NIHR Funding and Awards website for further award information.

Transanal irrigation as a therapeutic option for patients with incontinence and severe chronic constipation refractory to first-line treatment

INTRODUCTION

The aim is to evaluate the utility of transanal irrigation such as treatment of incontinence and severe chronic constipation which is refractory to first-line therapy, and to assess its impact into the symptomatology and quality of life.

METHODS

Observational retrospective study of patients with incontinence and chronic constipation that had initiated transanal irrigation in two hospitals of the region. We collect sociodemographic variables, comorbidity, previous treatments, tests, parameters and incidences during the irrigation, and punctuation in the Cleveland Clinic Incontinence and Constipation Scores and EuroQol-5D Quality Of Life Scale before and after the treatment.

RESULTS

40 patients, 20 with incontinence and 20 with chronic constipation. After an average period of 9 months of treatment, in 14 patients with incontinence we have observed a mean clinical improvement of 7,45 points before-after treatment measured with Cleveland Clinic Incontinence Score, and a mean improvement of 23 points in their quality of life before-after treatment measured with EQ5D Scale (P < .001); and in 16 patients with constipation a mean clinical improvement of 7,6 points before-after treatment measured with Cleveland Clinic Constipation Score, and a mean improvement of 31,5 points in their quality of life before-after treatment measured with EQ5D Scale (P < .001).

CONCLUSIONS

Transanal irrigation is an effective therapy for patients with incontinence and chronic constipation that are refractory to first-line therapies. It's an easy, self-administered and safe procedure. When the patient learns how to use it, the symptomatology and quality of life are improved.

[Gastrointestinal tract involvement in systemic sclerosis]

Gastrointestinal tract involvement in systemic sclerosis concerns more than 90% of patients but is of heterogeneous clinical expression. It can involve the entire intestinal tract and be responsible for multifactorial malnutrition, which is frequent in this disease. It is a major source of deterioration in the quality of life and can even be life-threatening. Management is complex and multidisciplinary, ranging from simple hygienic and dietary measures, to specialized endoscopic or surgical interventional procedures, also including medical treatments, particularly proton pump inhibitors and prokinetics, with potential side effects. Ongoing research for new diagnostic and therapeutic tools promises to improve the management and prognosis of these patients.

Transanal irrigation in functional bowel disorders and LARS: short-term results from an Italian national study

PURPOSE

To evaluate the potential benefits associated with the short-term (6 months) treatment with transanal irrigation (TAI) in patients suffering from functional constipation (FC), functional fecal incontinence (FI), and low anterior resection syndrome (LARS).

METHODS

A multicenter observational study (12 centers; 369 patients) was conducted to assess the following primary and secondary objectives: to evaluate the level of satisfaction regarding bowel control and quality of life (QoL); to evaluate bowel symptoms severity and dropout frequency and reason. To this aim, validated questionnaires were provided to the patients at baseline (T0) and after 6 months of TAI treatment (T6) performed with the medical device Peristeen® Plus (Coloplast A/S, Denmark). Statistical analyses were conducted to compare the outcomes obtained at T0 and T6.

RESULTS

A 6-month treatment with TAI enabled a statistically significant (p < 0.05) improvement of QoL scores, satisfaction scores regarding bowel control, and severity indexes of disorder-related symptoms in patients suffering from FC, FI, and LARS. Globally, 8.0% of patients discontinued the treatment after 6 months as a result of occurrence of symptoms (2.4%) or other justifications (3.8%) such as personal reasons. None of the dropouts were due to treatment inefficacy.

CONCLUSION

Results of the present study suggest that short-term TAI treatment is beneficial for patients suffering from functional bowel disorders and LARS. Future analysis of prospective data will focus on the clinical outcomes associated with the long-term use (up to 24 months) of TAI when dealing with these types of medical conditions.

Transanal Irrigation for People With Neurogenic Bowel Dysfunction: An Integrative Literature Review

Transanal irrigation has been introduced as a complement to standard bowel care for people with neurogenic bowel dysfunction. There is no contemporary integrative review of the effectiveness and feasibility of transanal irrigation from a holistic nursing perspective, only fragments of evidence to date. The aim was to investigate the effectiveness and feasibility of transanal irrigation for people with neurogenic bowel dysfunction. An integrative literature review was conducted. Nineteen studies were included. According to the results, transanal irrigation can reduce difficulties associated with defecation, episodes of incontinence, and the time needed for evacuation and bowel care. Transanal irrigation can increase general satisfaction with bowel habits and quality of life and decrease level of dependency. However, there are practical problems to overcome and adverse effects to manage. Discontinuation is relatively common. The results support the effectiveness of transanal irrigation, but feasibility is inconclusive. Users, including caregivers, report practical problems, and compliance was not always easy to achieve. It is important that users, including caregivers, are well informed and supported during transanal irrigation treatment, especially during introduction. The quality of the studies found was generally weak; therefore, high-quality quantitative and qualitative studies are needed on the topic.

Transanal irrigation at a glance

This article provides a brief overview of transanal irrigation (TAI). It covers the rationale behind the procedure, the contraindications, possible complications and considerations for patient education and support.

Advanced Management Protocol of Transanal Irrigation in Order to Improve the Outcome of Pediatric Patients with Fecal Incontinence

Background: Transanal irrigation (TAI) is employed for children with fecal incontinence, but it can present several problems which require a study of their outcomes among different pathologies and without a tailored work up. The aim of our study was to evaluate the effectiveness of an advanced protocol in order to tailor TAI, prevent complications, and evaluate outcomes. Methods: We included 70 patients (14 anorectal malformation, 12 Hirschsprung’s disease, 24 neurological impairment, 20 functional incontinence) submitted to a comprehensive protocol with Peristeen^®: fecal score, volumetric enema, rectal ultrasound, anorectal 3D manometry, and diary for testing and parameter adjustment. Results: Among the patients, 62.9% needed adaptations to the parameters, mainly volume of irrigated water and number of puffs of balloon. These adaptations were positively correlated with pre-treatment manometric and enema data. In each group, the improvement of score was statistically significant in all cases (p 0.000); the main factor influencing the efficacy was the rate of sphincter anomalies. The ARM group had slower improvement than other groups, whereas functional patients had the best response. Conclusions: Our results showed that TAI should not be standardized for all patients, because each one has different peculiarities; evaluation of patients before TAI with rectal ultrasound, enema, and manometry allowed us to tailor the treatment, highlighting different outcomes among various pathologies, thus improving the efficacy.

Long-term results of sacral neuromodulation for the treatment of anorectal diseases

INTRODUCTION

Sacral neuromodulation (SNM) aims to improve anorectal function in patients with disorders of anal continence and rectal emptying. The mechanism of action of SNM is not well known, and its indications are still under evaluation. We report the functional results and morbidity of a prospective cohort treated between 2002 and 2019.

RESULTS

A total of 284 patients (of 423 tested) had implantation of a SNM. Five patients (1.8%) were lost to follow-up. Among those who had implantation, the indications for SNM were anal incontinence (n=376), refractory constipation (n=17), anterior resection syndrome (n=13), solitary rectal ulcer syndrome (n=7), and chronic inflammatory bowel disease (IBD) (n=10). The morbidity rate was 2.7% (Dindo-Clavien>2), 33 patients (11%) required explantation for infection (n=5), pain (n=2), inefficacy (n=24) or other reasons (rectal cancer) (n=3). It was necessary to change the stimulator in 68 patients (24%) during the follow-up period. Regarding the group of patients with anal incontinence, functional results showed improvement of the incontinence score in 40% and of quality of life in 25% after a mean follow-up of 55months.

CONCLUSION

SNM constitutes a mini-invasive treatment associated with low morbidity. Its' efficacy in anal incontinence makes it a priority approach. Other indications are still under evaluation; while results are promising, they are highly variable.

Adherence to transanal irrigation in older adults: first-year assessment

BACKGROUND

While the prevalence of chronic constipation and fecal incontinence increases with age, few data on transanal irrigation in older adults are available. The aim of this study was to assess the adherence and predictive factors for adherence to transanal irrigation during the first year of use in older adults.

METHODS

This retrospective study included all patients over 65 years old, who had therapeutic education for transanal irrigation with the Peristeen® device between January 2010 and July 2019 in a neuro-urology department of a university hospital in France. The adherence rate was assessed at 1, 3, 6, and 12 months. Predictive factors for adherence were looked for by comparing persistent population and non-persistent population at 1, 3, 6, and 12 months.

RESULTS

Sixty-nine patients over 65 years old were included. The adherence rate was 73.9% at 1 month, 55.1% at 3 months, 46.4% at 6 months, and 40.1% at 1 year. No predictive factor for adherence to transanal irrigation was identified.

CONCLUSIONS

Adherence to transanal irrigation during the first year in older adults remains close to that in the adult general population. Predictive factors of adherence remain unclear.

Transanal Irrigation for Neurogenic Bowel Disease, Low Anterior Resection Syndrome, Faecal Incontinence and Chronic Constipation: A Systematic Review

Transanal irrigation (TAI) has received increasing attention as a treatment option in patients with bowel dysfunction. This systematic review was conducted according to the PRISMA guidelines and evaluates the effect of TAI in neurogenic bowel dysfunction (NBD), low anterior resection syndrome (LARS), faecal incontinence (FI) and chronic constipation (CC). The primary outcome was the effect of TAI on bowel function. Secondary outcomes included details on TAI, quality of life (QoL), the discontinuation rate, adverse events, predictive factors for a successful outcome, and health economics. A systematic search for articles reporting original data on the effect of TAI on bowel function was performed, and 27 eligible studies including 1435 individuals were included. Three randomised controlled trials, one non-randomised trial, and 23 observational studies were included; 70% of the studies were assessed to be of excellent or good methodological quality. Results showed an improvement in bowel function among patients with NBD, LARS, FI, and CC with some studies showing improvement in QoL. However, discontinuation rates were high. Side effects were common, but equally prevalent among comparative treatments. No consistent predictive factors for a successful outcome were identified. Results from this review show that TAI improves bowel function and potentially QoL; however, evidence remains limited.

Treatments in neurogenic bowel dysfunctions: evidence reviews and clinical recommendations in adults

INTRODUCTION

Neurogenic bowel dysfunction (NBD) is an impairment of defecation control due to any nervous system lesion negatively affecting physical health status and quality of life. We aimed at systematically assessing all available evidence on NBD treatment in adults and providing clinical management guidance and recommendations.

EVIDENCE ACQUISITION

PICOs and questions (N.=7) were identified by an expert panel. We searched for and retrieved evidence from the PUBMED and EMBASE databases, limited to the English language and the Western countries context, related to any type of setting and published from 2009 to 2019. Health effects, patient values, preferences and resource use were assessed. Of all, only RCTs, observational studies and systematic reviews on adult population (≥18 years) were analyzed. The study was conducted according to PRISMA guidelines and Cochrane recommendations. The effect size, if possible, was calculated for the interpretation of the outcomes, and evidence was assessed through the GRADE method.

EVIDENCE SYNTHESIS

Thirty-one studies were included in our qualitative synthesis. Evidence is generally scarce. Most of the outcomes are narratively described and therefore defined by imprecision. Besides, most of the included studies are affected by risk of bias. Digital stimulation was found to be effective in short term follow-up. The pharmacological treatment choice, combined or alone, needs to be balanced case by case considering clinical history, setting of use and bowel management protocol. According to only one RCT supporting evidence mainly in persons affected by spinal cord injury (SCI), trans-anal irrigation (TAI) improves QoL and patient independency with a significant reduction of time spent for defecation and daily bowel program. History of urinary infections predicts the choice of using TAI. Patient-reported efficacy of colostomy alone or in combination with other surgeries appears evident in terms of patient's satisfaction and QoL over time. Nonetheless, perioperative and late complications can occur and may result in reduced acceptability over time.

CONCLUSIONS

Evidence is somehow weak and mainly reported in SCI. The systematic use of assistive interventions does not reduce the need of conservative or invasive approaches. Studies are needed on the role of bowel management in protecting patients from complications secondary to NBD in long term follow-ups.

Use of a new transanal irrigation device for bowel disorder management by patients familiar with the irrigation technique: a prospective, interventional, multicenter pilot study

BACKGROUND

The aim of this study was to evaluate the feasibility of transanal irrigation (TAI) with a new medical device incorporating an electric pump, the IryPump®R Set.

METHODS

An interventional, prospective, open-label, non-comparative, multicenter pilot study on TAI was conducted at three French university hospitals. Patients with experience of TAI were enrolled for a 1-month period during which 5 consecutive TAIs were performed using the IryPump®R Set (B.Braun Melsungen AG Melsungen, Germany). The study's primary efficacy criterion was successful TAI, defined as (i) use of the patient's usual irrigation volume of water, (ii) stool evacuation, and (iii) the absence of leakage between TAIs. The first two TAIs were not taken into account in the main analysis. The secondary outcome measures were device acceptability, bowel dysfunction scores, tolerability, and safety.

RESULTS

Fifteen patients were included between November 2016 and May 2017, and 14 were assessed in the main analysis. The TAI success rate was 72.4% (21 out of 29 procedures). The bowel dysfunction scores at the end of the study did not differ significantly from those recorded on inclusion. A high proportion of patients (> 70%) reported that TAI was feasible with the new medical device. There were no serious adverse events or device-related adverse events. At the end of the study, 50% of the participants were willing to consider further use of the new device.

CONCLUSIONS

In patients familiar with TAI, using a new medical device incorporating an electric pump was feasible. Levels of patient satisfaction were high, especially with regard to comfort of use and a feeling of security during TAI.

Assessment of Needs in Children Suffering From Refractory Non-neurogenic Urinary and Fecal Incontinence and Their Caregivers' Needs and Attitudes Toward Alternative Therapies (SNM, TENS)

Background: Non-neurogenic urinary and fecal incontinence (UI, FI) affects approximately 6% of North American children with 1% of cases becoming refractory (nonresponsive to standard therapies). Incontinence has major potential long-term physiological and psychological implications for patients and their families. While Sacral Neuromodulation (SNM) and Transcutaneous Nerve Stimulation (TENS) are alternative therapies available for the treatment of refractory UI/FI, these are not approved for use in children in Canada. The present study assessed participants' perception of current treatments, incontinence burden, and attitudes toward novel therapies in a single pediatric institution. Methods: Multiple validated questionnaires including Dysfunctional Voiding Scoring System (DVSS), Bristol Stool Chart (BSC), Pediatric Incontinence measurement (PinQ), and Time-Driven Activity Based Costing were used to perform a needs assessment for patients with non-neurogenic refractory incontinence, and to determine patients' and caregivers' attitudes toward alternative therapies. Results: 75% of patients and 89% of caregivers reported a moderate to severe impact of incontinence on QoL with diminished social interactions among the primary concerns. Caregivers were frustrated with current treatments and were open to trying alternative therapies (SNM and TENS), which, at least in the case of SNM, seems to be less expensive, possibly less burdensome and more effective than current surgical options. Conclusion: Pediatric refractory UI/FI has a large impact on patients' and caregivers' QoL and alternative therapies with the potential to improve QoL of patients and caregivers should be further investigated as a substitute for surgery.

Malone Antegrade Continence Enemas vs. Cecostomy vs. Transanal Irrigation-What Is New and How Do We Counsel Our Patients?

PURPOSE OF REVIEW

No gold standard exists for managing neurogenic bowel dysfunction, specifically in individuals with spina bifida. Since the International Children's Continence Society published its consensus document on neurogenic bowel treatment in 2012, an increased focus on why we must manage bowels and how to improve our management has occurred. This review provides updated information for clinicians.

RECENT FINDINGS

A surge in research, mostly retrospective, has been conducted on the success and satisfaction of three types of management for neurogenic bowel. All three management techniques have relatively high success rates for fecal continence and satisfaction rates. Selection of which treatment to carry out still is debated among clinicians. Transanal irrigation is a safe and effective management option for neurogenic bowel that does not require surgery. Antegrade enemas can be carried out via cecostomy tube or Malone antegrade continence enema with similar fecal continence outcomes.