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Xu L, Fu C, Zhang Q, Xiong F, Peng L, Liang Z, Chen L, He C, Wei Q. Efficacy of biofeedback, repetitive transcranial magnetic stimulation and pelvic floor muscle training for female neurogenic bladder dysfunction after spinal cord injury: a study protocol for a randomised controlled trial. BMJ Open 2020; 10:e034582. [PMID: 32759239 PMCID: PMC7409967 DOI: 10.1136/bmjopen-2019-034582] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 05/14/2020] [Accepted: 06/23/2020] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Neurogenic bladder dysfunction is prevalent in female patients with spinal cord injury (SCI), and previous guidelines have recommended pelvic floor muscle training (PFMT) for first-line conservative treatment. However, the actual regimen of PFMT varies widely and the single treatment does not satisfy the need of some patients. Therefore, this study aims to provide a detailed rationale and methodology for comparing the effectiveness of PFMT, biofeedback and repetitive transcranial magnetic stimulation (rTMS) as adjunct treatments for neurogenic bladder dysfunction. METHODS AND ANALYSIS This trial is a single-centre randomised controlled trial for female patients with urinary incontinence (UI) in phase of chronic SCI. Eligible participants will be randomised to one of four arms: (1) PFMT, (2) PFMT with biofeedback, (3) PFMT and rTMS and (4) PFMT with biofeedback and rTMS. There will be 44 participants in each arm and all the subjects will undergo 20 treatment sessions, five times a week for 4 weeks. The outcomes will be evaluated at 4 weeks, 3 months and 6 months after randomisation. The primary outcome is the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form, and the secondary outcomes include bladder diary, pelvic floor muscle function and the International Spinal Cord Injury Quality of Life Basic Data Set. ETHICS AND DISSEMINATION The Clinical Research and Biomedical Ethics Committee of the West China Hospital, Sichuan University has approved this trial and the approval number is 2019-885. All participants will be provided written informed consent after verification of the eligibility criteria. The results of this study will be accessible in peer-reviewed publications and be presented at academic conferences. TRIAL REGISTRATION NUMBER Chinese Clinical Trial Registry (ChiCTR1900026126).
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Affiliation(s)
- Lin Xu
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, PR China
| | - Chenying Fu
- State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
| | - Qing Zhang
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, PR China
| | - Feng Xiong
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, PR China
| | - Lihong Peng
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, PR China
| | - Zejun Liang
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, PR China
| | - Li Chen
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, PR China
| | - Chengqi He
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, PR China
| | - Quan Wei
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, PR China
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Rogers RG, Bann CM, Barber MD, Fairchild P, Lukacz ES, Arya L, Markland AD, Siddiqui NY, Sung VW. The responsiveness and minimally important difference for the Accidental Bowel Leakage Evaluation questionnaire. Int Urogynecol J 2020; 31:2499-2505. [PMID: 32613557 PMCID: PMC7680270 DOI: 10.1007/s00192-020-04367-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 05/25/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION AND HYPOTHESIS We describe the responsiveness and minimally important difference (MID) of the Accidental Bowel Leakage Evaluation (ABLE) questionnaire. METHODS Women with bowel leakage completed ABLE, Patient Global Impression of Improvement, Colo-Rectal Anal Distress Inventory, and Vaizey questionnaires pretreatment and again at 24 weeks post-treatment. Change scores were correlated between questionnaires. Student's t tests compared ABLE change scores for improved versus not improved based on other measures. The MID was determined by anchor- and distribution-based approaches. RESULTS In 266 women, the mean age was 63.75 (SD = 11.14) and 79% were white. Mean baseline ABLE scores were 2.32 ± 0.56 (possible range 1-5) with a reduction of 0.62 (SD = 0.79) by 24 weeks. ABLE change scores correlated with related measures change scores (r = 0.24 to 0.53) and differed between women who improved and did not improve (all p < 0.001). Standardized response means for participants who improved were large ranging from -0.89 to -1.12. Distribution-based methods suggest a MID of -0.19 based on the criterion of one SEM and -0.28 based on half a standard deviation. Anchor-based MIDs ranged from -0.10 to -0.45. We recommend a MID of -0.20. CONCLUSIONS The ABLE questionnaire is responsive to change, with a suggested MID of -0.20.
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Affiliation(s)
- Rebecca G Rogers
- Department of Women's Health, Dell Medical School, 1501 Red River Street, Austin, TX, 78712, USA.
- University of New Mexico Health Sciences Center, Albuquerque, NM, USA.
| | - Carla M Bann
- Division of Statistical and Data Sciences, RTI International, Research Triangle Park, NC, USA
| | - Matthew D Barber
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
- Obstetrics Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Pamela Fairchild
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Magee-Women's Research Institute, Pittsburgh, PA, USA
| | - Emily S Lukacz
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California at San Diego, San Diego, CA, USA
| | - Lily Arya
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, USA
| | - Alayne D Markland
- Department of Medicine, University of Alabama at Birmingham; Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Birmingham, AL, USA
| | - Nazema Y Siddiqui
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - Vivian W Sung
- Department of Obstetrics and Gynecology, Alpert Medical School of Brown University, Providence, RI, USA
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Andy UU, Jelovsek JE, Carper B, Meyer I, Dyer KY, Rogers RG, Mazloomdoost D, Korbly NB, Sassani JC, Gantz MG. Impact of treatment for fecal incontinence on constipation symptoms. Am J Obstet Gynecol 2020; 222:590.e1-590.e8. [PMID: 31765640 DOI: 10.1016/j.ajog.2019.11.1256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 10/17/2019] [Accepted: 11/17/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Defecatory symptoms, such as a sense of incomplete emptying and straining with bowel movements, are paradoxically present in women with fecal incontinence. Treatments for fecal incontinence, such as loperamide and biofeedback, can worsen or improve defecatory symptoms, respectively. The primary aim of this study was to compare changes in constipation symptoms in women undergoing treatment for fecal incontinence with education only, loperamide, anal muscle exercises with biofeedback or both loperamide and biofeedback. Our secondary aim was to compare changes in constipation symptoms among responders and nonresponders to fecal incontinence treatment. STUDY DESIGN This was a planned secondary analysis of a randomized controlled trial comparing 2 first-line therapies for fecal incontinence in a 2 × 2 factorial design. Women with at least monthly fecal incontinence and normal stool consistency were randomized to 4 groups: (1) oral placebo plus education only, (2) oral loperamide plus education only, (3) placebo plus anorectal manometry-assisted biofeedback, and (4) loperamide plus biofeedback. Defecatory symptoms were measured using the Patient Assessment of Constipation Symptoms questionnaire at baseline, 12 weeks, and 24 weeks. The Patient Assessment of Constipation Symptoms consists of 12 items that contribute to a global score and 3 subscales: stool characteristics/symptoms (hardness of stool, size of stool, straining, inability to pass stool), rectal symptoms (burning, pain, bleeding, incomplete bowel movement), and abdominal symptoms (discomfort, pain, bloating, cramps). Scores for each subscale as well as the global score range from 0 (no symptoms) to 4 (maximum score), with negative change scores representing improvement in defecatory symptoms. Responders to fecal incontinence treatment were defined as women with a minimally important clinical improvement of ≥5 points on the St Mark's (Vaizey) scale between baseline and 24 weeks. Intent-to-treat analysis was performed using a longitudinal mixed model, controlling for baseline scores, to estimate changes in Patient Assessment of Constipation Symptoms scores from baseline through 24 weeks. RESULTS At 24 weeks, there were small changes in Patient Assessment of Constipation Symptoms global scores in all 4 groups: oral placebo plus education (-0.3; 95% confidence interval, -0.5 to -0.1), loperamide plus education (-0.1, 95% confidence interval, -0.3 to0.0), oral placebo plus biofeedback (-0.3, 95% confidence interval, -0.4 to -0.2), and loperamide plus biofeedback (-0.3, 95% confidence interval, -0.4 to -0.2). No differences were observed in change in Patient Assessment of Constipation Symptoms scores between women randomized to placebo plus education and those randomized to loperamide plus education (P = .17) or placebo plus biofeedback (P = .82). Change in Patient Assessment of Constipation Symptoms scores in women randomized to combination loperamide plus biofeedback therapy was not different from that of women randomized to treatment with loperamide or biofeedback alone. Responders had greater improvement in Patient Assessment of Constipation Symptoms scores than nonresponders (-0.4; 95% confidence interval, -0.5 to -0.3 vs -0.2; 95% confidence interval, -0.3 to -0.0, P < .01, mean difference, 0.2, 95% confidence interval, 0.1-0.4). CONCLUSION Change in constipation symptoms following treatment of fecal incontinence in women are small and are not significantly different between groups. Loperamide treatment for fecal incontinence does not worsen constipation symptoms among women with normal consistency stool. Women with clinically significant improvement in fecal incontinence symptoms report greater improvement in constipation symptoms.
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Affiliation(s)
- Uduak U Andy
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA.
| | - J Eric Jelovsek
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | | | - Isuzu Meyer
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | - Keisha Y Dyer
- Department of Obstetrics and Gynecology, Kaiser Permanente, San Diego, CA
| | - Rebecca G Rogers
- Department of Women's Health, Dell Medical School, University of Texas at Austin. Austin, TX; University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
| | - Nicole B Korbly
- Department of Obstetrics and Gynecology, Alpert Medical School of Brown University, Providence, RI
| | - Jessica C Sassani
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh Medical Center, Pittsburgh, PA
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Accidental Bowel Leakage Evaluation: A New Patient-Centered Validated Measure of Accidental Bowel Leakage Symptoms in Women. Dis Colon Rectum 2020; 63:668-677. [PMID: 32032195 PMCID: PMC7243684 DOI: 10.1097/dcr.0000000000001596] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Questionnaires assessing accidental bowel leakage lack important patient-centered symptoms. OBJECTIVE We aimed to create a valid measure of accidental bowel leakage symptoms. DESIGN We previously created a conceptual framework capturing patient-centered accidental bowel leakage symptoms. The framework included bowel leakage type, severity and bother, and ancillary bowel symptoms, including predictability, awareness, leakage control, emptying disorders, and discomfort. SETTINGS The study was conducted in outpatient clinics. PATIENTS Women with at least monthly accidental bowel leakage were included. INTERVENTIONS Participants completed the Accidental Bowel Leakage Evaluation at baseline and 12 and 24 weeks, as well as bowel diaries and other validated pelvic floor questionnaires. A subset completed items twice before treatment. Final item selection was based on psychometric properties and clinical importance. MAIN OUTCOME MEASURES Psychometric analyses included Cronbach α, confirmatory factor, and item response theory analyses. Construct validity was based on correlations with measures of similar constructs. RESULTS A total of 296 women completed baseline items, and 70 provided test-retest data. The cohort was predominately white (79%) and middle aged (64 ± 11 y). Confirmatory factor analyses supported the conceptual framework. The final 18-item scale demonstrated good internal consistency (Cronbach α = 0.77-0.90) and test-retest reliability (intraclass correlation = 0.80). Construct validity was demonstrated with baseline and 12- and 24-week scale scores, which correlated with the Vaizey (r = 0.52, 0.68, and 0.69), Colorectal Anal Distress Inventory (r = 0.54, 0.65, 0.71), Colorectal Anal Impact Questionnaire (r = 0.48, 0.53, 0.53), and hygiene (r = 0.39, 0.43, 0.49) and avoidance subscales scores of the adaptive index (r = 0.45, 0.44, 0.43) and average number of pad changes per day on bowel diaries (r = 0.35, 0.38, 0.31; all p < 0.001). LIMITATIONS The study was limited by nature of involving validation in a care-seeking population. CONCLUSIONS The Accidental Bowel Leakage Evaluation instrument is a reliable, patient-centered measure with good validity properties. This instrument improves on currently available measures by adding patient-important domains of predictability, awareness, control, emptying, and discomfort. See Video Abstract at http://links.lww.com/DCR/B172. EVALUACIóN DE FUGA INTESTINAL ACCIDENTAL: UNA NUEVA MEDIDA VALIDADA Y CENTRADA EN PACIENTES FEMENINOS CON SíNTOMAS DE FUGA INTESTINAL ACCIDENTAL: Los cuestionarios que evalúan la fuga intestinal accidental, carecen de síntomas centrados en el paciente.Nuestro objetivo fue crear una medida válida de síntomas de fuga intestinal accidental.Previamente creamos un marco conceptual centrado en el paciente, para capturar síntomas de fuga intestinal accidental. El marco incluía tipo de fuga intestinal, gravedad, molestia, y síntomas intestinales auxiliares, incluyendo previsibilidad, conciencia, control de fugas, trastornos de vaciado e incomodidad.Clínicas de pacientes externos.Mujeres con al menos una fuga intestinal accidental mensual.Las participantes completaron la Evaluación de Fuga Intestinal Accidental al inicio del estudio y a las 12 y 24 semanas, así como diarios intestinales y otros cuestionarios validados del piso pélvico. Un subconjunto completó los elementos dos veces antes del tratamiento. La selección final del elemento se basó en las propiedades psicométricas y la importancia clínica.Los análisis psicométricos incluyeron el Alfa de Cronbach, factor confirmatorio y análisis de la teoría de respuesta al elemento. La validez de constructo se basó en correlaciones con medidas de constructos similares.Un total de 296 mujeres completaron los elementos de referencia y 70 proporcionaron datos de test-retest. La cohorte fue predominantemente blanca (79%) y de mediana edad (64 +/- 11 años). Análisis factorial confirmatorio respaldó el marco conceptual. La escala final de 18 elementos, demostró una buena consistencia interna (Alfa de Cronbach = 0,77-0,90) y fiabilidad test-retest (correlación intraclase = 0,80). La validez de constructo se demostró con puntajes de escala de referencia de 12 y 24 semanas que se correlacionaron con Vaizey (r = 0,52, 0,68 y 0,69), Inventario de Ansiedad colorecto anal (r = 0,54, 0,65, 0,71), Cuestionarios de Impacto colorecto anal (r = 0,48, 0,53, 0,53) e higiene (r = 0,39, 0,43, 0,49), puntuaciones de subescalas de evitación del índice adaptativo (r = 0,45, 0,44, 0,43), número promedio de cambios de almohadilla por día, de los diarios intestinales (r = 0.35, 0.38, 0.31), todos p <.001.Validación de una población en busca de atención.El instrumento de Evaluación de Fuga Intestinal Accidental es una medida confiable, centrada en el paciente y con buenas propiedades de validez. Este instrumento mejora las medidas actualmente disponibles, al agregar dominios importantes para el paciente de previsibilidad, conciencia, control, vaciado e incomodidad. Consulte Video Resumen en http://links.lww.com/DCR/B172. (Traducción-Dr. Fidel Ruiz Healy).
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Characteristics Associated With Clinically Important Treatment Responses in Women Undergoing Nonsurgical Therapy for Fecal Incontinence. Am J Gastroenterol 2020; 115:115-127. [PMID: 31895722 PMCID: PMC7197976 DOI: 10.14309/ajg.0000000000000482] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To identify baseline clinical and demographic characteristics associated with clinically important treatment responses in a randomized trial of nonsurgical therapies for fecal incontinence (FI). METHODS Women (N = 296) with FI were randomized to loperamide or placebo- and manometry-assisted biofeedback exercises or educational pamphlet in a 2 × 2 factorial design. Treatment response was defined in 3 ways from baseline to 24 weeks: minimal clinically important difference (MID) of -5 points in St. Mark's score, ≥50% reduction in FI episodes, and combined St. Mark's MID and ≥50% reduction FI episodes. Multivariable logistic regression models included baseline characteristics and treatment groups with and without controlling for drug and exercise adherence. RESULTS Treatment response defined by St. Mark's MID was associated with higher symptom severity (adjusted odds ratio [aOR] 1.20, 95% confidence interval [CI] 1.11-1.28) and being overweight vs normal/underweight (aOR 2.15, 95% CI 1.07-4.34); these predictors remained controlling for adherence. Fifty percent reduction in FI episodes was associated with the combined loperamide/biofeedback group compared with placebo/pamphlet (aOR 4.04, 95% CI 1.36-11.98), St. Mark's score in the placebo/pamphlet group (aOR 1.29, 95% CI 1.01-1.65), FI subtype of urge vs urge plus passive FI (aOR 2.39, 95% CI 1.09-5.25), and passive vs urge plus passive FI (aOR 3.26, 95% CI 1.48-7.17). Controlling for adherence, associations remained, except St. Mark's score. DISCUSSION Higher severity of FI symptoms, being overweight, drug adherence, FI subtype, and combined biofeedback and medication treatment were associated with clinically important treatment responses. This information may assist in counseling patients, regarding efficacy and expectations of nonsurgical treatments of FI.
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Jelovsek JE. Biofeedback or loperamide for faecal incontinence in women – Author's reply. Lancet Gastroenterol Hepatol 2019; 4:904-905. [DOI: 10.1016/s2468-1253(19)30334-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 08/30/2019] [Indexed: 10/25/2022]
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Sacral neuromodulation versus onabotulinumtoxinA for refractory urgency urinary incontinence: impact on fecal incontinence symptoms and sexual function. Am J Obstet Gynecol 2019; 221:513.e1-513.e15. [PMID: 31211964 DOI: 10.1016/j.ajog.2019.06.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 05/17/2019] [Accepted: 06/10/2019] [Indexed: 12/18/2022]
Abstract
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.
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Jelovsek JE, Markland AD, Whitehead WE, Barber MD, Newman DK, Rogers RG, Dyer K, Visco AG, Sutkin G, Zyczynski HM, Carper B, Meikle SF, Sung VW, Gantz MG. Controlling faecal incontinence in women by performing anal exercises with biofeedback or loperamide: a randomised clinical trial. Lancet Gastroenterol Hepatol 2019; 4:698-710. [PMID: 31320277 PMCID: PMC6708078 DOI: 10.1016/s2468-1253(19)30193-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 05/08/2019] [Accepted: 05/09/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Well designed, large comparative effectiveness trials assessing the efficacy of primary interventions for faecal incontinence are few in number. The objectives of this study were to compare different combinations of anorectal manometry-assisted biofeedback, loperamide, education, and oral placebo. METHODS In this randomised factorial trial, participants were recruited from eight clinical sites in the USA. Women with at least one episode of faecal incontinence per month in the past 3 months were randomly assigned 0·5:1:1:1 to one of four groups: oral placebo plus education only, placebo plus anorectal manometry-assisted biofeedback, loperamide plus education only, and loperamide plus anorectal manometry-assisted biofeedback. Participants received 2 mg per day of loperamide or oral placebo with the option of dose escalation or reduction. Women assigned to biofeedback received six visits, including strength and sensory biofeedback training. All participants received a standardised faecal incontinence patient education pamphlet and were followed for 24 weeks after starting treatment. The primary endpoint was change in St Mark's (Vaizey) faecal incontinence severity score between baseline and 24 weeks, analysed by intention-to-treat using general linear mixed modelling. Investigators, interviewers, and outcome evaluators were masked to biofeedback assignment. Participants and all study staff other than the research pharmacist were masked to medication assignment. Randomisation took place within the electronic data capture system, was stratified by site using randomly permuted blocks (block size 7), and the sizes of the blocks and the allocation sequence were known only to the data coordinating centre. This trial is registered with ClinicalTrials.gov, number NCT02008565. FINDINGS Between April 1, 2014, and Sept 30, 2015, 377 women were enrolled, of whom 300 were randomly assigned to placebo plus education (n=42), placebo plus biofeedback (n=84), loperamide plus education (n=88), and the combined intervention of loperamide plus biofeedback (n=86). At 24 weeks, there were no differences between loperamide versus placebo (model estimated score change -1·5 points, 95% CI -3·4 to 0·4, p=0·12), biofeedback versus education (-0·7 points, -2·6 to 1·2, p=0·47), and loperamide and biofeedback versus placebo and biofeedback (-1·9 points, -4·1 to 0·3, p=0·092) or versus loperamide plus education (-1·1 points, -3·4 to 1·1, p=0·33). Constipation was the most common grade 3 or higher adverse event and was reported by two (2%) of 86 participants in the loperamide and biofeedback group and two (2%) of 88 in the loperamide plus education group. The percentage of participants with any serious adverse events did not differ between the treatment groups. Only one serious adverse event was considered related to treatment (small bowel obstruction in the placebo and biofeedback group). INTERPRETATION In women with normal stool consistency and faecal incontinence bothersome enough to seek treatment, we were unable to find evidence against the null hypotheses that loperamide is equivalent to placebo, that anal exercises with biofeedback is equivalent to an educational pamphlet, and that loperamide and biofeedback are equivalent to oral placebo and biofeedback or loperamide plus an educational pamphlet. Because these are common first-line treatments for faecal incontinence, clinicians could consider combining loperamide, anal manometry-assisted biofeedback, and a standard educational pamphlet, but this is likely to result in only negligible improvement over individual therapies and patients should be counselled regarding possible constipation. FUNDING Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Institutes of Health Office of Research on Women's Health.
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Affiliation(s)
- J Eric Jelovsek
- Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA.
| | - Alayne D Markland
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Birmingham, AL, USA
| | - William E Whitehead
- Department of Gastroenterology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Matthew D Barber
- Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - Diane K Newman
- Division of Urology, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Rebecca G Rogers
- Departments of Obstetrics and Gynecology and Surgery, University of New Mexico Health Sciences Center, Albuquerque, NM, USA; Department of Women's Health, Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | - Keisha Dyer
- Department of Obstetrics and Gynecology, Kaiser Permanente, San Diego, CA, USA
| | - Anthony G Visco
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - Gary Sutkin
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Magee-Womens Research Institute, Pittsburgh, PA, USA; Department of Obstetrics and Gynecology, University of Missouri, Kansas City, MO, USA
| | - Halina M Zyczynski
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Magee-Womens Research Institute, Pittsburgh, PA, USA
| | | | | | - Vivian W Sung
- Department of Obstetrics and Gynecology, Alpert Medical School of Brown University, Providence, RI, USA
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9
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Arya LA, Richter HE, Jelovsek E, Gantz M, Cichowski S, Zyczynski H, Dyer K, Siddiqui N, Carberry C, Broeckling C, Morrow C, Kashyap P, Meikle S. Metabolites and microbial composition of stool of women with fecal incontinence: Study design and methods. Neurourol Urodyn 2017; 37:634-641. [PMID: 28763566 DOI: 10.1002/nau.23360] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Accepted: 06/24/2017] [Indexed: 12/17/2022]
Abstract
AIMS This paper aims to report the rationale, design, and the specific methodology of an ongoing nested observational study that will determine the association of the metabolite and microbial composition of stool with fecal incontinence (FI). METHODS Eligible cases are participants with FI enrolled in the Controlling Anal Incontinence in women by Performing Anal Exercises with Biofeedback or Loperamide (CAPABLe) trial, a Pelvic Floor Disorders Network trial across eight clinical centers in the United States. Women of similar age without FI in the last year served as controls. All subject collected stool samples at the baseline and 24-week visit at home using a standardized collection method. Samples were shipped to and stored at centralized laboratories. RESULTS Specimen collection commenced December 2014 and was completed in May 2016. Fecal water and DNA has been extracted and is currently being analyzed by targeted metabolic profiling for stool metabolites and 16S rRNA gene sequencing for stool microbiota. CONCLUSIONS This article describes the rationale and design of a study that could provide a paradigm shift for the treatment of FI in women.
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Affiliation(s)
- Lily A Arya
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Holly E Richter
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Eric Jelovsek
- Obstetrics and Gynecology and Women's Health Institute, Center for Urogynecology and Reconstructive Pelvic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Marie Gantz
- Social, Statistical and Environmental Sciences, RTI International, Research Triangle Park, North Carolina
| | - Sara Cichowski
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Halina Zyczynski
- Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics, Gynecology and Reproductive Sciences, Women's Center for Bladder and Pelvic Health, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Keisha Dyer
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Reproductive Medicine, UC San Diego Health System, San Diego, California
| | - Nazema Siddiqui
- Division of Urogynecology, Department of Obstetrics and Gynecology, Duke Medical Center, Durham, North Carolina
| | - Cassandra Carberry
- Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Corey Broeckling
- Colorado State University Proteomics and Metabolomics Facility, Fort Collins, Colorado
| | - Casey Morrow
- Department of Microbiome Resources, University of Alabama, Birmingham, Alabama
| | - Purna Kashyap
- Division of Gastroenterology, Department of Internal Medicine, The Mayo Clinic, Rochester, Minnesota
| | - Susie Meikle
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD for the Pelvic Floor Disorders Network, Rockville, Maryland
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10
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Epidemiology, Pathophysiology and Management of Fecal Incontinence in the Older Woman. CURRENT GERIATRICS REPORTS 2017. [DOI: 10.1007/s13670-017-0201-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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11
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Lamin E, Strother MC, Smith AL. The Evidence for Female Pelvic Medicine Interventions. CURRENT BLADDER DYSFUNCTION REPORTS 2017. [DOI: 10.1007/s11884-017-0399-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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12
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Markland AD, Jelovsek JE, Whitehead WE, Newman DK, Andy UU, Dyer K, Harm-Ernandes I, Cichowski S, McCormick J, Rardin C, Sutkin G, Shaffer A, Meikle S. Improving biofeedback for the treatment of fecal incontinence in women: implementation of a standardized multi-site manometric biofeedback protocol. Neurogastroenterol Motil 2017; 29:10.1111/nmo.12906. [PMID: 27453154 PMCID: PMC5198255 DOI: 10.1111/nmo.12906] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 06/20/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Standardized training and clinical protocols using biofeedback for the treatment of fecal incontinence (FI) are important for clinical care. Our primary aims were to develop, implement, and evaluate adherence to a standardized protocol for manometric biofeedback to treat FI. METHODS In a Pelvic Floor Disorders Network (PFDN) trial, participants were enrolled from eight PFDN clinical centers across the United States. A team of clinical and equipment experts developed biofeedback software on a novel tablet computer platform for conducting standardized anorectal manometry with separate manometric biofeedback protocols for improving anorectal muscle strength, sensation, and urge resistance. The training protocol also included education on bowel function, anal sphincter exercises, and bowel diary monitoring. Study interventionists completed online training prior to attending a centralized, standardized certification course. For the certification, expert trainers assessed the ability of the interventionists to perform the protocol components for a paid volunteer who acted as a standardized patient. Postcertification, the trainers audited interventionists during trial implementation to improve protocol adherence. KEY RESULTS Twenty-four interventionists attended the in-person training and certification, including 46% advanced practice registered nurses (11/24), 50% (12/24) physical therapists, and 4% physician assistants (1/24). Trainers performed audio audits for 88% (21/24), representing 84 audited visits. All certified interventionists met or exceeded the prespecified 80% pass rate for the audit process, with an average passing rate of 93%. CONCLUSIONS & INFERENCES A biofeedback protocol can be successfully imparted to experienced pelvic floor health care providers from various disciplines. Our process promoted high adherence to a standard protocol and is applicable to many clinical settings.
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Affiliation(s)
- Alayne D. Markland
- Department of Medicine, Division of Gerontology, Geriatrics and Palliative Care, University of Alabama at Birmingham, Birmingham, AL & the Birmingham Veterans Affairs Medical Center, Geriatric Research, Education, and Clinical Center
| | - J. Eric Jelovsek
- Obstetrics, Gynecology & Women’s Health Institute, Cleveland Clinic, Cleveland, OH
| | - William E. Whitehead
- Department of Medicine (Division of Gastroenterology and Hepatology), and Department of Obstetrics and Gynecology (Division of Urogynecology) University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Diane K. Newman
- Department of Surgery, Division of Urology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Uduak U. Andy
- Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Keisher Dyer
- Department of Obstetrics and Gynecology Kaiser Permanente, San Diego, CA
| | - Ingrid Harm-Ernandes
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - Sara Cichowski
- Departments of Obstetrics and Gynecology and Surgery, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Jeannine McCormick
- Department of Medicine, Division of Gerontology, Geriatrics and Palliative Care, University of Alabama at Birmingham, Birmingham, AL & the Birmingham Veterans Affairs Medical Center, Geriatric Research, Education, and Clinical Center
| | - Charles Rardin
- Department of Obstetrics and Gynecology, Alpert Medical School of Brown University, Providence, RI
| | - Gary Sutkin
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Susan Meikle
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
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13
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Abstract
Fecal incontinence is a highly prevalent and distressing condition that has a negative impact on quality of life. The etiology is often multifactorial, and the evaluation and treatment of this condition can be hindered by a lack of understanding of the mechanisms and currently available treatment options. This article reviews the evidence-based update for the management of fecal incontinence.
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Affiliation(s)
- Isuzu Meyer
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, 1700 6th Avenue South, Suite 10382, Birmingham, AL 35233, USA.
| | - Holly E Richter
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, 1700 6th Avenue South, Suite 10382, Birmingham, AL 35233, USA
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14
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Meyer I, Richter HE. An Evidence-Based Approach to the Evaluation, Diagnostic Assessment and Treatment of Fecal Incontinence in Women. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2014; 3:155-164. [PMID: 25505643 PMCID: PMC4258837 DOI: 10.1007/s13669-014-0085-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Fecal incontinence (FI) is a debilitating disorder which negatively impacts quality of life. The etiology is often multifactorial and although most women with FI are able to be treated, many remain untreated because a significant proportion of women do not report their symptoms and seek care. The evaluation and treatment of FI can be also hindered by a lack of understanding of the mechanisms and current options. This article provides a review on the evidence-based evaluation and management for FI.
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Affiliation(s)
- Isuzu Meyer
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, 1700 6th Avenue South, Suite 10382, Birmingham, AL 35233, ,
| | - Holly E Richter
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, 1700 6th Avenue South, Suite 10382, Birmingham, AL 35233, ,
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