Evaluation and treatment of anal incontinence, constipation, and defecatory dysfunction

Continence: Bowel and Bladder and Physical Function Decline in Women

Purpose of review

The purpose of this article is to review the various forms of incontinence, highlight their impact on older women, and to explore current literature regarding the link between physical activity, physical function, and incontinence.

Recent findings

Both urinary and fecal incontinence become more prevalent with age, and are associated with significant morbidity. In parallel, there is a well-established decline in physical function that occurs with age. Furthermore, incontinence has a bidirectional relationship with physical function decline. Given the known link between increasing physical activity and preserved physical function, there is an emerging body of literature seeking to determine whether increases in physical activity may also improve incontinence outcomes. We review some recent data on this topic.

Summary

Continence and physical function are two closely linked entities. Further research is needed to determine whether interventions that increase physical activity might result in improved continence outcomes.

Evaluation and management of defecatory dysfunction in women

PURPOSE OF REVIEW

To summarize the current recommendations for the evaluation and management of defecatory dysfunction in women and highlight key relationships between defecatory dysfunction and other pelvic floor disorders, including pelvic organ prolapse, fecal incontinence, and voiding dysfunction.

RECENT FINDINGS

Conservative measures including lifestyle modifications, pharmacotherapy, and biofeedback continue to be the mainstay of treatment with newer therapies emerging. Physiologic testing and/or radiologic imaging should be considered for those who fail conservative therapy or are clinically complex. Surgical management is appropriate for carefully selected patients with anatomic causes of defecatory dysfunction. Further research is needed on surgical outcomes and patient expectations.

SUMMARY

Pelvic floor disorders, including defecatory dysfunction, have a significant societal impact and are highly prevalent among women. Given its potential complexity, a broader focus is needed when evaluating women with defecatory symptoms and effective treatment may require multidisciplinary care.

Two Etiological Reasons of Constipation: Anterior Rectocele and Internal Mucosal Intussusception

Chronic constipation is a common problem in the general population. Rome III criteria can be used for the diagnosis of chronic constipation. The aim of this study is to emphasize the importance of anterior rectocele and mucosal intussusception as two etiological factors for chronic constipation. One hundred patients were included in this study after excluding other causes of the constipation by medical history, physical examination, and laboratory and radiological studies in 108 total patients who were admitted consecutively to the outpatient clinic of the general surgery department of Dr. Sadi Konuk Bakirkoy Education and Research Hospital with the complaint of constipation between June 2009 and January 2010. It was found that 75 % of these patients had anterior rectocele and 66 % of them had internal intussusception which cause chronic constsipation. Anterior rectocele and internal rectal mucosal intussusception must be kept in mind as two significant reasons for chronic functional constipation.

Symptom outcomes important to women with anal incontinence: a conceptual framework

OBJECTIVE

To develop a framework that describes the most important symptom outcomes for anal incontinence treatment from the patient perspective.

METHODS

A conceptual framework was developed by the Pelvic Floor Disorders Network based on four semistructured focus groups and confirmed in two sets of 10 cognitive interviews including women with anal incontinence. We explored: 1) patient-preferred terminology for describing anal incontinence symptoms; 2) patient definitions of treatment "success"; 3) importance of symptoms and outcomes in the framework; and 4) conceptual gaps (defined as outcomes not previously identified as important). Sessions were conducted according to grounded theory transcribed, coded, and qualitatively and quantitatively analyzed to identify relevant themes. Content and face validity of the framework were further assessed using cognitive interviews.

RESULTS

Thirty-four women participated in focus groups and 20 in cognitive interviews. Overall, 29 (54%) were aged 60 years or older, 42 (78%) were white, and 10 (19%) had a high school degree or less. Two overarching outcome themes were identified: "primary bowel leakage symptoms" and "ancillary bowel symptoms." Subdomains important in primary bowel leakage symptoms included leakage characteristics (symptom frequency, amount of leakage, symptom bother) and conditions when bowel leakage occurs (predictability, awareness, urgency). Subdomains important under ancillary bowel symptoms included emptying disorders (constipation, obstructed defecation, and wiping issues) and discomfort (pain, burning). New outcomes identified included predictability, awareness, wiping issues, and discomfort.

CONCLUSION

Women with anal incontinence desire a wide range of symptom outcomes after treatment. These are captured in our conceptual framework, which can aid clinicians and researchers in assessing anal incontinence. LEVEL OF EVIEDENCE: II.

Changes in bowel symptoms 1 year after rectocele repair

OBJECTIVE

We sought to evaluate changes in bowel symptoms after rectocele repair and identify risk factors for persistent symptoms.

STUDY DESIGN

We conducted ancillary analysis of a randomized surgical trial for rectocele repair. Subjects underwent examinations and completed questionnaires for bowel symptoms at baseline and 12 months postoperatively. Outcomes included resolution, persistence, or de novo bowel symptoms. We used multiple logistic regression to identify risk factors for bowel symptom persistence.

RESULTS

A total of 160 women enrolled: 139 had baseline bowel symptoms and 85% had 12-month data. The prevalence of bowel symptoms decreased after rectocele repair (56% vs 23% splinting, 74% vs 37% straining, 85% vs 19% incomplete evacuation, 66% vs 14% obstructive defecation; P < .001 for all). On multiple logistic regression, a longer history of splinting was a risk factor for persistent postoperative splinting (adjusted odds ratio, 2.25; 95% confidence interval, 1.02-4.93).

CONCLUSION

Bowel symptoms may improve after rectocele repair, but almost half of women will have persistent symptoms.

Triple target treatment (3T) is more effective than biofeedback alone for anal incontinence: the 3T-AI study

PURPOSE

The efficacy of EMG-biofeedback and low-frequency electrical stimulation for the treatment of anal incontinence has not been proven. Our purpose was to evaluate a novel therapeutic concept, termed triple target treatment, which combines amplitude-modulated medium-frequency stimulation and EMG-biofeedback.

METHODS

Patients with anal incontinence were randomly assigned to the triple target regimen or EMG-biofeedback alone for a 9-month treatment period in a multicenter randomized clinical trial with blinded observers (ClincialTrials.gov registration number NCT00525291). Primary end points were changes in the Cleveland Clinic score and the adapted St. Mark's (Vaizey) score at 9 months compared with baseline. Secondary end points included therapy acceptance and proportion of patients achieving continence or improvement in grade or frequency of incontinence.

RESULTS

We enrolled 158 patients with anal incontinence. The median decrease in the Cleveland Clinic score from baseline to 9 months was 3 points greater for the triple target regimen than for EMG-biofeedback (95% CI, 1-4; P = .0024). The improvement was 8 points for the triple target regimen (95% CI, 7-9) and 5 points for EMG-biofeedback (95% CI, 4-7). Results were similar for the Vaizey score. Of patients treated for at least 3 months, continence was achieved by 50% of patients with the triple target regimen and 25.8% of those with EMG-biofeedback.

CONCLUSIONS

The combination of amplitude-modulated medium-frequency electrostimulation with EMG-biofeedback in the triple target regimen is superior to EMG-biofeedback alone in the treatment of anal incontinence. Therapy programs for fecal incontinence are most effective if patients participate for longer than 2 to 3 months.