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

Colonoscopic findings in patients with pelvic floor dysfunction

BACKGROUNDY

Colonoscopy is often performed in the initial workup of pelvic floor dysfunction, even in the absence of red flag symptoms. Current guidelines suggest colonoscopy is only required in the presence of rectal bleeding, diarrhoea or change in bowel habit. The aim of this study was to evaluate the prevalence of significant pathology found at colonoscopy in patients with pelvic floor dysfunction.

METHODS

Retrospective chart review was performed on all patients presenting to a functional colorectal outpatient clinic between May 2018 and August 2019. Information was collected on presenting symptoms, whether colonoscopy had been performed within 5 years, quality of bowel preparation, withdrawal time, number of polyps detected, histology, presence of diverticular disease, colorectal malignancy, inflammatory bowel disease, solitary rectal ulcer or rectal prolapse.

RESULTS

There were 260 patients seen within the study period, of which 67% had undergone recent colonoscopy within the last 5 years. The mean age was 53 and 219 (84%) patients were female. Average withdrawal time was 13 min. Polyps were found in 48.7% and adenomas in 32.4% of all colonoscopies. The adenoma detection rate was 32.7%. None of the colonoscopies found evidence of malignancy. A new diagnosis of inflammatory bowel disease was discovered in two patients.

CONCLUSION

There was low rates of serious pathology such as malignancy or inflammatory bowel disease in patients referred to a functional clinic. However, colonoscopy is still useful in workup of pelvic floor dysfunction, as many patients have erratic bowel habits or vague symptoms, and will have adenomas found.

Critical appraisal of international guidelines for the management of fecal incontinence in adults: is it possible to define what to do in different clinical scenarios?

Fecal incontinence (FI) is a complex often multifactorial functional disorder which is associated with a significant impact on patients’ quality of life. There is a broad spectrum of symptoms, and degrees of severity and diverse patient backgrounds. Several treatment algorithms from different professional societies and experts are available in the literature. However, no consensus has been reached on several aspects of FI management. We performed a critical review of the most recently published guidelines on FI, emphasising the lack of consensus, highlighting specific topics mentioned in each of the guidelines that are not covered in the others and defining the treatment proposed in different clinical scenarios.

Dynamic transperineal ultrasonography correlates with prolonged pudendal nerve latency in female with fecal incontinence

The pelvic floor is a complex anatomical entity and its neuromuscular assessment is evaluated through debated neurophysiological tests. An innovative approach is the study of pelvic floor through dynamic transperineal ultrasound (DTU). The aim of this study is to evaluate DTU sensitivity in recognizing patients with fecal incontinence and to evaluate its concordance with the results of the motor latency studied via pudendal nerve terminal motor latency (PNTML). Female patients affected by FI addressed to our center of coloproctology were prospectively assessed. After a coloproctological evaluation, comprising the PNTML assessment to identify pudendal neuropathy, patients were addressed to DTU to determine anterior and posterior displacement of puborectalis muscle by a blinded coloproctologist. In order to compare the data, a cohort of female healthy volunteers was enrolled. Sixty-eight subjects (34 patients and 34 healthy volunteers) were enrolled. The sensitivities of anterior displacement, posterior displacement and either anterior or posterior displacement in determining the fecal incontinence were 82%, 67% and 91%, respectively. A further high correlation of either anterior or posterior displacement with PTNML was also noted (88%). DTU is an indirect, painless and reproducible method for the identification of the pelvic floor neuromuscular integrity. Its findings seem to highly correlate with FI symptoms and with PNTML results. In the near future, after larger comparative studies, DTU would be considered a potential reliable non-invasive and feasible indirect procedure in the identification of fecal incontinence by pudendal neuropathy. Trial registration number is NCT03933683.

Comparative analysis of occlusion methods for artificial sphincters

An artificial sphincter is a device that replaces the function of the biological sphincter by occluding the relative biological lumen. The investigation of occlusion methods for artificial sphincters is crucial for a reliable and effective design of such devices. The compression induced onto the tissue by a certain pressure depends on the biomechanical and physiological features of the lumen and on the specific occlusion method. A numerical model and an experimental evaluation are presented here to assess the efficiency of different occlusion methods. Numerical models of circumferential occlusion and clamping occlusion methods to simulate the compression of the biological lumen were developed. Results revealed a relationship between the efficiency of the occlusion method and the physiological condition of the lumen. With differences related to the testing setup, this relationship was also confirmed experimentally by conducting tests on biological simulators. We analyzed the occlusion method to adopt as the physiological pressure (ie, leakage pressure values) changed. In particular, we focused on the urinary incontinence, which is a dysfunction involving the external sphincter surrounding the urethra. In this scenario, we demonstrated that a clamping occlusion is an efficient method to compress the urethra, whose physiological pressures range between 4 and 12 kPa. The clamping occlusion method resulted up to 35% more efficient in terms of sealing pressure than the circumferential one for a closing pressure varying between 2.3 and 11.5 kPa.

Pelvic floor rehabilitation for defecation disorders

Pelvic floor rehabilitation is frequently recommended for defecation disorders, in both constipation and fecal incontinence. However, the lack of patient selection, together with the variety of rehabilitation methods and protocols, often jeopardize the results of this approach, causing difficulty in evaluating outcomes and addressing proper management, and above all, in obtaining scientific evidence for the efficacy of these methods for specific indications. The authors represent different gastroenterological and surgical scientific societies in Italy, and their aim was to identify the indications and agree on treatment protocols for pelvic floor rehabilitation of patients with defecation disorders. This was achieved by means of a modified Delphi method, utilizing a working team (10 members) which developed the statements and a consensus group (15 members, different from the previous ones) which voted twice also suggesting modifications of the statements.

Conservative treatment of severe defecatory urgency and fecal incontinence: minor strategies with major impact

BACKGROUND

Bowel disturbances have been identified as the most important risk factor for fecal incontinence (FI). However, few studies have evaluated the impact of fiber supplementation. Our aim was to assess the correlation between the improvement in stool consistency by fiber supplementation and the changes in urgency and number of FI episodes and in the QoL of patients with FI.

METHODS

Eighty-three patients who came to our institution with FI and/or fecal urgency associated with loose stools or diarrhea were prospectively included in the study The intervention included dietary advice and methylcellulose 500 mg every 8 h for 6 weeks. All assessments were carried out at baseline and 6 weeks after the start of the intervention, and included a Bristol Stool Scale, a 3-week bowel diary, the St Mark's score, the Fecal Incontinence Quality of Life scale (FIQL) and a bowel satisfaction score.

RESULTS

Sixty-one patients completed the study. At baseline 50 reported episodes of urge incontinence, while 11 did not report FI episodes because they rarely left home to avoid leakage. The Bristol score improved to normal stools in 65.6% of patients after treatment. Bowel diaries showed a statistically significant reduction in the number of bowel movements, urge episodes, urge fecal incontinence episodes and soiling per week. The St Mark's score and the bowel satisfaction score significantly improved after methylcellulose and overall deferment time also increased. FIQL significantly improved in two subdomains (lifestyle, coping/behavior). Thirty-one patients (51.7%) were discharged with methylcellulose as the only treatment.

CONCLUSIONS

FI may significantly improve with methylcellulose in selected cases. Assessment of fecal consistency and initial treatment with methylcellulose could be started at primary care level to reduce the need for specialist referral.

Present status and perspectives of endosonography 2017 in gastroenterology

Endoscopic ultrasound has become an essential tool in modern gastroenterology and abdominal surgery. Compared with all other endoscopic methods, it has the most potential for innovation and its future looks bright. Thus, we compiled this summary of established and novel applications of endoscopic ultrasound methods to inform the reader about what is already possible and where future developments will lead in improving patient care further. This review is structured in four parts. The first section reports on developments in diagnostic endoscopic ultrasound, the second looks at semi-invasive endoscopic ultrasound, and the third discusses advances in therapeutic endoscopic ultrasound. An overview on the future prospects of endoscopic ultrasound methods concludes this article.

A systematic review and meta-analysis of the treatment of anal fissure

BACKGROUND

Anal fissure has a very large number of treatment options. The choice is difficult. In an effort to assist in that, choice presented here is a systematic review and meta-analysis of all published treatments for anal fissure that have been studied in randomized controlled trials.

METHODS

Randomized trials were sought in the Cochrane Controlled Trials Register, Medline, EMBASE and the trials registry sites clinicaltrials.gov and who/int/ictrp/search/en. Abstracts were screened, full-text studies chosen, and finally eligible studies selected and abstracted. The review was then divided into those studies that compared two or more surgical procedures and those that had at least one arm that was non-surgical. Studies were further categorized by the specific interventions and comparisons. The outcome assessed was treatment failure. Negative effects of treatment assessed were headache and anal incontinence. Risk of bias was assessed for each study, and the strength of the evidence of each comparison was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach.

RESULTS

One hundred and forty-eight eligible trials were found and assessed, 31 in the surgical group and 117 in the non-surgical group. There were 14 different operations described in the surgical group and 29 different non-surgical treatments in the non-surgical group along with partial lateral internal sphincterotomy (LIS). There were 61 different comparisons. Of these, 47 were reported in 2 or fewer studies, usually with quite small patient samples. The largest single comparison was glyceryl trinitrate (GTN) versus control with 19 studies. GTN was more effective than control in sustained cure (OR 0.68; 95% CI 0.63-0.77), but the quality of evidence was very poor because of severe heterogeneity, and risk of bias due to inadequate clinical follow-up. The only comparison to have a GRADE quality of evidence of high was a subgroup analysis of LIS versus any medical therapy (OR 0.12; CI 0.07-0.21). Most of the other studies were downgraded in GRADE due to imprecision.

CONCLUSIONS

LIS is superior to non-surgical therapies in achieving sustained cure of fissure. Calcium channel blockers were more effective than GTN and with less risk of headache, but with only a low quality of evidence. Anal incontinence, once thought to be a frequent risk with LIS, was found in various subgroups in this review to have a risk between 3.4 and 4.4%. Among the surgical studies, manual anal stretch performed worse than LIS in the treatment of chronic anal fissure in adults. For those patients requiring surgery for anal fissure, open LIS and closed LIS appear to be equally efficacious, with a moderate GRADE quality of evidence. All other GRADE evaluations of procedures were low to very low due mostly to imprecision.

Pudendal nerve testing does not contribute to surgical decision making following anorectal testing in patients with faecal incontinence

PURPOSE

Faecal incontinence (FI) is a debilitating condition, which affects approximately 2-17 % of the population. Clinical assessment, physiological testing and imaging are usually used to evaluate the pathophysiology and guide management of FI. By analysing patient characteristics, symptoms and investigative findings, the aim of this study was to identify which patient characteristics and investigations influence patient management.

METHODS

Data was prospectively collected for all patients with FI presenting to a single surgeon at the Royal Prince Alfred Hospital, Sydney, between March 2002 and September 2013. Continuous data was analysed using the independent T-test. Categorical data was analysed using chi-square tests and logistic regression.

RESULTS

Three hundred ninety-eight patients were reviewed; 96 % were female and the mean age was 57 years. Surgical intervention was recommended for 185 patients (47 %) should biofeedback fail. Independent predictors for surgical recommendation were prolapse (p < 0.001, adjusted OR = 4.9 [CI 2.9-8.2]), a functional sphincter length <1 cm (p = 0.032, OR = 1.7 [CI 1.1-2.8]), an external anal sphincter defect (p = 0.028, OR = 1.8 [CI 1.1-3.1]) and a Cleveland Clinic Incontinence Score ≥10 (p = 0.029, OR = 1.7 [CI 1.1-2.6]).

CONCLUSION

Independent predictors of surgical recommendation included the presence of prolapse, a functional sphincter length <1 cm, an external anal sphincter defect and a Cleveland Clinic Incontinence Score ≥ 10. Pudendal neuropathy was not a predictor of surgical intervention, leading us to question the utility of this investigation.