Fecal incontinence

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.

Long-term effects on pressure and electromyography in a rat model of anal sphincter injury

PURPOSE

The goal of this research was to study the chronic effects of pudendal nerve transection and sphincterotomy on the anal sphincter, because there is no good animal model investigating anal sphincter injury. Clinically, anal sphincter dysfunction impacts a cohort of women who have fecal incontinence; conclusions from the study can benefit research for new effective treatments.

METHODS

Sixty-eight virgin Sprague-Dawley rats were allocated into control (n = 12), sphincterotomy (n = 28), and pudendal nerve transection (n = 28) groups and were evaluated before injury and immediately, 4 days, 14 days, and 28 days after. Anal pressures and electromyography were recorded and statistically compared. The anal sphincter was submitted to histology.

RESULTS

: Sphincterotomy data showed anal pressure recovery 14 days after injury and were comparable to controls after 28 days. Pudendal nerve transection showed a significant decrease in anal pressure 4 days after injury (P < .001), and this continued until 28 days after injury (P = .01). Electromyography showed significant loss of activity after nerve transection compared with controls. Twenty-eight days after sphincterotomy and nerve transection, fibrosis and muscle atrophy of the external anal sphincter muscle were demonstrated, respectively.

CONCLUSION

Anal pressures recover significantly after sphincterotomy. Pudendal nerve transection caused atrophy of the external anal sphincter that was reflected by decreased pressures and electromyography. The results of this study can contribute to a better understanding of the mechanisms that lead to fecal incontinence and can be used to test the efficacy of therapies.

Chinese female nurses' perceptions of male genitalia-related care--Part 2

AIMS

This study was designed to investigate Chinese female nurses' perceptions of certain male genitalia-related care and the influence of their demography and experiences on their perceptions.

BACKGROUND

Several physical conditions, in which male genitalia-related care is required, have been found to have considerable negative impact on male patients, leading to decreased quality of life and psychosocial and sexual dysfunctions. Available studies suggest that Chinese female nurses' conduct during the provision of male genitalia-related care is negative. However, the evidence is weak with respect of the degree of Chinese nurses' negativity and what the contributory factors may be.

DESIGN

Survey.

METHODS

Chinese female nurses in nine units in five hospitals were surveyed. Of 378 returned questionnaires, 312 were usable, and 138 contained textual comments. Numerical data were analysed using spss 14.0, and textual data were analysed using thematic analysis. RESULTS; The majority of participants had never performed genital wound care, perineal area shaving, perineal hygiene, suprapubic and urinary catheterisation. More than half preferred only bladder irrigation and washout to be performed by nurses and preferred the other male genitalia-related care to be performed by a male. Participants tended to agree meatal cleansing, perineal area shaving, perineal hygiene and urinary catheterisation were embarrassing, awkward and intrusive, but to disagree that they were sexual, dirty, stigmatizing or having an impact on the male patient's sexual health.

CONCLUSION

This study suggests that Chinese female nurses play limited roles in the practice of male genitalia-related care, but their perceptions of such care are not negative.

RELEVANCE TO CLINICAL PRACTICE

Given the increasing move of Chinese female nurses to other countries, sexuality, sexual harassment, privacy and the constraints of traditional Chinese beliefs on sexuality over professional nursing conduct should be emphasised in clinical training programmes.

A review of the psychosocial issues for nurses in male genitalia-related care

AIM

This literature review aimed to highlight psychosocial issues for nurses in the practice of male genitalia-related care so as to guide the improvement of the teaching and practice of male genitalia-related care.

BACKGROUND

Male genitalia-related care is common in hospitals and in the community. In several conditions, e.g. incontinence, postradiotherapy or following operation for cancer of genitalia, bladder, colon or rectum, patients will require male genitalia-related care. Patients who require male genitalia-related care may encounter psychosocial and/or sexual dysfunction. In the holistic approach to men's health, nurses are expected to meet patients' psychosocial and sexual needs, while the literature suggests that nurses' perceptions and attitudes in providing certain male genitalia-related care, e.g. genital hygiene, sexual counselling, are negative.

METHOD

Systematic literature review.

CONCLUSION

Issues surrounding male genitalia-related care for nurses are complicated and may be related to privacy, intimacy, sexuality, dirty work and emotional discomfort. Age, gender, race and social class could compound these issues. Relevance to clinical practice. Nurses' negative perceptions, responses and attitudes towards male genitalia-related care may exacerbate patients' conditions under which male genitalia-related care is required. Appropriate strategies should be developed to overcome these problems.

Surgical strategies for faecal incontinence--a decision analysis between dynamic graciloplasty, artificial bowel sphincter and end stoma

BACKGROUND

Artificial bowel sphincter (ABS) and dynamic graciloplasty (DG) are surgical treatments for faecal incontinence (FI). FI may affect quality of life (QOL) so severely that patients are often willing to consider a permanent end stoma (ES). It is unclear which is the more cost-effective strategy.

METHOD

Probability estimates for patients with FI were obtained from published data (ABS, n = 319; DG, n = 301), supplemented by expert opinion. The primary outcome was quality-adjusted life years (QALYs) gained from each strategy. Factors considered were the risk of failure of the primary and redo operation and the consequent risk of permanent stoma. Results were assessed as incremental cost-effectiveness ratio (ICER).

RESULTS

Over the 5-year time horizon, ES gave a QALY gain of 3.45 for 16,280 pounds sterling, giving an ICER of 4719 pounds sterling/QALY. ABS produced a gain of 4.38 QALYs for 23,569 pounds sterling, giving an ICER of 5387 pounds sterling/QALY. DG produced a gain of 4.00 QALYs for 25,035 pounds sterling, giving an ICER of 6257 pounds sterling/QALY. With the willingness-to-pay threshold set at 30,000 pounds sterling/QALY, ES was the most cost-effective intervention. The ABS was most cost-effective after 10 years.

CONCLUSION

All three procedures were found to be cost-effective. The ES was most cost-effective over 5 years, while the ABS was most cost-effective in excess of 10. DG maybe considered as an alternative in specialist centres.

MR Defecography in Patients with Fecal Incontinence: Imaging Findings and Their Effect on Surgical Management

PURPOSE

To retrospectively evaluate magnetic resonance (MR) defecography findings in patients with fecal incontinence who were evaluated for surgical treatment and to assess the influence of MR defecography on surgical therapy.

MATERIALS AND METHODS

Institutional review board approval was obtained. Informed consent was waived; however, written informed consent for imaging was obtained. Fifty patients (44 women, six men; mean age, 61 years) with fecal incontinence were placed in a sitting position and underwent MR defecography performed with an open-configuration MR system. Midsagittal T1-weighted MR images were obtained at rest, at maximal contraction of the sphincter, and at defecation. Images were prospectively and retrospectively reviewed by two independent observers for a variety of findings. Interobserver agreement was analyzed by calculating kappa statistics. Prospective interpretation of MR defecography findings was used to influence surgical therapy, and retrospective interpretation was used for concomitant pelvic floor disorders.

RESULTS

MR defecography revealed rectal descent of more than 6 cm (relative to the pubococcygeal line) in 47 (94%) of 50 patients. A bladder descent of more than 3 cm was present in 20 (40%) of 50 patients, and a vaginal vault descent of more than 3 cm was present in 19 (43%) of 44 women. Moreover, 17 (34%) anterior proctoceles, 16 (32%) enteroceles, and 10 (20%) rectal prolapses were noted. Interobserver agreement was good to excellent (kappa = 0.6-0.91) for image analysis results. MR defecography findings led to changes in the surgical approach in 22 (67%) of 33 patients who underwent surgery.

CONCLUSION

MR defecography may demonstrate a variety of abnormal findings in patients who are considered candidates for surgical therapy for fecal incontinence, and the findings may influence the surgical treatment that is subsequently chosen.

SUPPLEMENTAL MATERIAL

http://radiology.rsnajnls.org/cgi/content/full/2402050648/DC1

Risk factors for female anal incontinence: new insight through the Evanston-Northwestern twin sisters study

OBJECTIVE

To evaluate risk factors for anal incontinence using an identical twin sisters study design to provide control over genetic variance.

METHODS

A total of 271 identical twin sister pairs (mean age 47 years) completed the validated Colorectal Anal Distress Inventory questionnaire detailing the presence and severity of anal incontinence. Data were analyzed using a stepwise logistic regression with repeated binary measures to account for correlated data within twin pairs. Three different statistical models were used to analyze nonobstetric as well as obstetric risk factors separately.

RESULTS

Significant risk factors for anal incontinence and higher Colorectal Anal Distress Inventory anal incontinence subscale scores included age 40 years or older (fecal: odds ratio [OR] 2.82, 95% confidence interval [CI] 1.21-6.0; flatal: OR 1.90, 95% CI 1.11-3.24), menopause (fecal: OR 2.10, 95% CI 1.15-3.8; flatal: OR 2.11, 95% CI 1.43-3.13), increasing parity (parity > or = 2; fecal: OR 3.09, 95% CI 1.25-7.65; flatal: OR 2.72, 95% CI 1.65-4.51), and the presence of stress urinary incontinence (fecal: OR 2.11, 95% CI 1.12-3.98; flatal: OR 1.72, 95% CI 1.14-2.59). Obesity was associated with significantly higher Colorectal Anal Distress Inventory anal incontinence subscale scores (mean difference 5.18, P = .007). Cesarean delivery after initiation of labor was associated with a lower prevalence of anal incontinence than vaginal birth; however, this difference was not statistically significant (17% compared with 4%, P = .11). No anal incontinence was noted in women who had only elective cesarean deliveries.

CONCLUSION

Age, menopause, obesity, parity, and stress urinary incontinence are the major risk factors for female anal incontinence.

[Fecal incontinence]

Diagnosis and management of fecal incontinence requires exact understanding of the anatomic and pathophysiologic principles involved and demands a methodical, stepwise approach. Despite the potential appeal of surgical intervention, a considerable number of patients can be helped by comparatively simple, noninvasive measures. Initial treatment should be medical, including biofeedback in combination with a bowel management program. In the presence of a severely denervated pelvic floor, physiotherapeutic techniques rarely give rise to a satisfactory and long-lasting response. Obvious external sphincter defects and patients who failed medical management are treated surgically. Many injuries of the external sphincter can be treated by direct sphincter repair. If patients with intact external sphincters are unresponsive to medical measures, descending perineum and resultant idiopathic fecal incontinence will improve by radio-frequency delivery, sacral nerve stimulation, or postanal plication. Patients with complex neurologic disorders or extensive sphincter defects or who have undergone previous unsuccessful attempts at repair of the puborectalis itself should be considered for dynamic gracilis plastic or an artificial sphincter.