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Muñoz JM, Groskreutz M, Compher C, Andy UU. Diet Intake After Diet Modification Intervention in Women With Fecal Incontinence. UROGYNECOLOGY (PHILADELPHIA, PA.) 2024:02273501-990000000-00211. [PMID: 38621418 DOI: 10.1097/spv.0000000000001480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
IMPORTANCE Older women with fecal incontinence (FI) who underwent diet modification intervention (DMI) showed significant improvement in FI symptoms. It is unclear whether improvement in symptoms was associated with objective changes in dietary intake quality. OBJECTIVES The primary aim was to determine if improvement in overall dietary intake quality was associated with improvement in FI symptoms. Our secondary aim was to evaluate whether individual food group consumption changes were associated with changes in FI symptoms. STUDY DESIGN This was an ancillary analysis of a prospective cohort study of women aged 65 years and older with FI who underwent DMI. Seven-day diet-and-bowel diaries at baseline and 6 weeks after DMI were examined for how frequently participants consumed food categories and FI triggers. Adherence to recommended dietary guidelines was assessed between 2 and 4 weeks using a 24-hour diet recall. Baseline and postintervention consumption were compared using the Wilcoxon signed rank test. Spearman correlation was used to compare dietary intake changes with FI symptom changes. RESULTS Twenty-four women completed the 24-hour diet recalls, and 17 women completed the 7-day diet-and-bowel diaries at baseline and 6 weeks. More participants who were adherent had clinically significant improvement in symptoms compared with those who were not adherent (70% vs 30%, P=0.57). Decreased consumption of saturated fats (P=0.01) and fried foods (P<0.001) was associated with improvement in FI symptoms. CONCLUSIONS In this small population, overall dietary intake quality was not associated with change in FI symptom improvement. Decreased intake of saturated fat and fried food was associated with FI symptom improvement.
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Affiliation(s)
- Jaclyn M Muñoz
- From the Division of Urogynecology, Department of OB/GYN, University of Pennsylvania School of Medicine
| | - Molly Groskreutz
- Department of Biobehavioral Health Science, University of Pennsylvania School of Nursing; Philadelphia, PA
| | - Charlene Compher
- Department of Biobehavioral Health Science, University of Pennsylvania School of Nursing; Philadelphia, PA
| | - Uduak U Andy
- From the Division of Urogynecology, Department of OB/GYN, University of Pennsylvania School of Medicine
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Moureau MK, Jones LM, Schmuhl NB, Brown HW. Men and women experience different barriers to care seeking for fecal incontinence. Neurourol Urodyn 2023; 42:1769-1776. [PMID: 37614056 PMCID: PMC10810259 DOI: 10.1002/nau.25266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 08/03/2023] [Accepted: 08/06/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Despite effective treatments for fecal incontinence (FI), FI remains underdiagnosed and undertreated. This study sought to characterize and compare rates of, delays in, experiences with, and barriers to care seeking for FI among men and women. METHODS This study was a secondary analysis of electronic survey data collected from adults with FI. The survey included the use of a validated instrument to assess FI severity and questions that now comprise a validated instrument for assessing barriers to care seeking for FI in women. Descriptive analyses characterized differences between men and women. χ2 testing for categorical variables and t-testing for normally distributed continuous variables compared statistical differences. RESULTS The sample (N = 548) was predominately female (84%), non-Hispanic White (90%), and insured (96%), with a mean Vaizey score (13.4 ± 5.3) consistent with moderate or severe FI. Care seeking rates (p = 0.81) and symptom duration before care seeking (p = 0.23) did not differ between women and men, but women were more likely than men to be told that effective treatments exist; most male and female respondents who sought care were offered treatment. Very few respondents had been asked about FI by a healthcare provider. Whereas normative thinking, limited life impact, and believing that a healthcare provider could not help were more common barriers to care seeking among men, avoidance, fear, and discouragement were more common in women. CONCLUSIONS Men and women with FI seek care at similar rates and after experiencing symptoms for a similar duration of time. Very few patients with FI have been screened for it by a healthcare provider. Barriers to FI care seeking are different for women and men, and men are less likely than women to be informed about effective treatments by a healthcare provider.
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Affiliation(s)
- Madeline K. Moureau
- Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health
| | - Lisa M. Jones
- Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health
| | | | - Heidi W. Brown
- Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health
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Rao SSC, Ahuja NK, Bharucha AE, Brenner DM, Chey WD, Deutsch JK, Kunkel DC, Moshiree B, Neshatian L, Reveille RM, Sayuk GS, Shapiro JM, Shah ED, Staller K, Wexner SD, Baker JR. Optimizing the Utility of Anorectal Manometry for Diagnosis and Therapy: A Roundtable Review and Recommendations. Clin Gastroenterol Hepatol 2023; 21:2727-2739.e1. [PMID: 37302444 PMCID: PMC10542660 DOI: 10.1016/j.cgh.2023.05.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 04/13/2023] [Accepted: 05/25/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND & AIMS Anorectal manometry (ARM) is a comprehensive diagnostic tool for evaluating patients with constipation, fecal incontinence, or anorectal pain; however, it is not widely utilized for reasons that remain unclear. The aim of this roundtable discussion was to critically examine the current clinical practices of ARM and biofeedback therapy by physicians and surgeons in both academic and community settings. METHODS Leaders in medical and surgical gastroenterology and physical therapy with interest in anorectal disorders were surveyed regarding practice patterns and utilization of these technologies. Subsequently, a roundtable was held to discuss survey results, explore current diagnostic and therapeutic challenges with these technologies, review the literature, and generate consensus-based recommendations. RESULTS ARM identifies key pathophysiological abnormalities such as dyssynergic defecation, anal sphincter weakness, or rectal sensory dysfunction, and is a critical component of biofeedback therapy, an evidence-based treatment for patients with dyssynergic defecation and fecal incontinence. Additionally, ARM has the potential to enhance health-related quality of life and reduce healthcare costs. However, it has significant barriers that include a lack of education and training of healthcare providers regarding the utility and availability of ARM and biofeedback procedures, as well as challenges with condition-specific testing protocols and interpretation. Additional barriers include understanding when to perform, where to refer, and how to use these technologies, and confusion over billing practices. CONCLUSIONS Overcoming these challenges with appropriate education, training, collaborative research, and evidence-based guidelines for ARM testing and biofeedback therapy could significantly enhance patient care of anorectal disorders.
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Affiliation(s)
- Satish S C Rao
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Georgia, Augusta University, Augusta, Georgia.
| | - Nitin K Ahuja
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Darren M Brenner
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois
| | - William D Chey
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Jill K Deutsch
- Section of Digestive Diseases, Department of Internal Medicine, Yale New Haven Hospital, Yale School of Medicine, New Haven, Connecticut
| | - David C Kunkel
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Baharak Moshiree
- Division of Gastroenterology and Hepatology, Atrium Health, Wake Forest Medical University, Charlotte, North Carolina
| | - Leila Neshatian
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, California
| | - Robert M Reveille
- Division of Gastroenterology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Gregory S Sayuk
- Division of Gastroenterology, Washington University School of Medicine, Veterans Affairs Medical Center, St. Louis, Missouri
| | | | - Eric D Shah
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Kyle Staller
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida
| | - Jason R Baker
- Department of Gastroenterology and Hepatology, Atrium Health, University of North Carolina, Charlotte, North Carolina
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Yang K, Tabung FK, Whitehead WE, Giovannucci EL, Chan AT, Staller K. Proinflammatory Diet Is Associated With Increased Risk of Fecal Incontinence Among Older Women: Prospective Results From the Nurses' Health Study. Clin Gastroenterol Hepatol 2023; 21:1657-1659.e3. [PMID: 35504561 PMCID: PMC9617809 DOI: 10.1016/j.cgh.2022.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/01/2022] [Accepted: 04/06/2022] [Indexed: 01/20/2023]
Abstract
Fecal incontinence (FI) is a debilitating gastrointestinal disorder with a devastating impact on quality of life,1,2 particularly on older women, partly because of unique risk factors including parity and menopause.2,3 Therefore, identifying modifiable factors, such as diet, are crucial for developing effective prevention strategies for FI among those at risk. We previously found higher dietary fiber intake was associated with lower FI risk,4 providing the first population-based data to connect diet and FI prevention. However, prospective evidence on other dietary factors and FI risk has been limited. Dietary patterns may be associated with gut microbiome characteristics, which may influence inflammatory responses in the gastrointestinal tract5 and drive neurosensory disturbances.6 Moreover, chronic inflammation may drive reduced muscle mass and function,7 and pelvic floor dysfunction is an established FI risk factor.1,2 We hypothesized that a proinflammatory dietary pattern may be associated with increased FI risk and tested this hypothesis in the Nurses' Health Study.
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Affiliation(s)
- Keming Yang
- Clinical and Translational Epidemiology Unit and Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Fred K Tabung
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Division of Medical Oncology, Department of Internal Medicine, The Ohio State University College of Medicine and Comprehensive Cancer Center, Columbus, Ohio
| | - William E Whitehead
- Center for Functional Gastrointestinal and Motility Disorders, Division of Gastroenterology and Hepatology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Edward L Giovannucci
- Department of Nutrition and Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Andrew T Chan
- Clinical and Translational Epidemiology Unit and Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Broad Institute of Massachusetts Institute of Technology and Harvard University, Cambridge, Massachusetts; Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kyle Staller
- Clinical and Translational Epidemiology Unit and Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
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Sharma A, Rao S. Editorial: faecal incontinence is prevalent in IBS, as are effective treatment options! Aliment Pharmacol Ther 2023; 57:1174-1175. [PMID: 37094309 DOI: 10.1111/apt.17486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Affiliation(s)
- Amol Sharma
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | - Satish Rao
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
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Bharucha AE, Knowles CH, Mack I, Malcolm A, Oblizajek N, Rao S, Scott SM, Shin A, Enck P. Faecal incontinence in adults. Nat Rev Dis Primers 2022; 8:53. [PMID: 35948559 DOI: 10.1038/s41572-022-00381-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/29/2022] [Indexed: 11/09/2022]
Abstract
Faecal incontinence, which is defined by the unintentional loss of solid or liquid stool, has a worldwide prevalence of ≤7% in community-dwelling adults and can markedly impair quality of life. Nonetheless, many patients might not volunteer the symptom owing to embarrassment. Bowel disturbances, particularly diarrhoea, anal sphincter trauma (obstetrical injury or previous surgery), rectal urgency and burden of chronic illness are the main risk factors for faecal incontinence; others include neurological disorders, inflammatory bowel disease and pelvic floor anatomical disturbances. Faecal incontinence is classified by its type (urge, passive or combined), aetiology (anorectal disturbance, bowel symptoms or both) and severity, which is derived from the frequency, volume, consistency and nature (urge or passive) of stool leakage. Guided by the clinical features, diagnostic tests and therapies are implemented stepwise. When simple measures (for example, bowel modifiers such as fibre supplements, laxatives and anti-diarrhoeal agents) fail, anorectal manometry and other tests (endoanal imaging, defecography, rectal compliance and sensation, and anal neurophysiological tests) are performed as necessary. Non-surgical options (diet and lifestyle modification, behavioural measures, including biofeedback therapy, pharmacotherapy for constipation or diarrhoea, and anal or vaginal barrier devices) are often effective, especially in patients with mild faecal incontinence. Thereafter, perianal bulking agents, sacral neuromodulation and other surgeries may be considered when necessary.
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Affiliation(s)
- Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
| | - Charles H Knowles
- Blizard Institute, Centre for Neuroscience, Surgery & Trauma, Queen Mary University of London, London, UK
| | - Isabelle Mack
- University Hospital, Department of Psychosomatic Medicine, Tübingen, Germany
| | - Allison Malcolm
- Department of Gastroenterology, Royal North Shore Hospital and University of Sydney, Sydney, New South Wales, Australia
| | - Nicholas Oblizajek
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Satish Rao
- Department of Gastroenterology, University of Georgia, Augusta, GA, USA
| | - S Mark Scott
- Blizard Institute, Centre for Neuroscience, Surgery & Trauma, Queen Mary University of London, London, UK
| | - Andrea Shin
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, IN, USA
| | - Paul Enck
- University Hospital, Department of Psychosomatic Medicine, Tübingen, Germany.
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Futaba K, Chen SC, Leung WW, Wong C, Mak T, Ng S, Gregersen H. Fecobionics Evaluation of Biofeedback Therapy in Patients With Fecal Incontinence. Clin Transl Gastroenterol 2022; 13:e00491. [PMID: 35363631 PMCID: PMC9132520 DOI: 10.14309/ctg.0000000000000491] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 03/21/2022] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Biofeedback therapy (BFT) is a well-known treatment for functional anorectal disorders. The effect of BFT was monitored in fecal incontinence (FI) patients with the Fecobionics test and with the conventional technologies, anorectal manometry (ARM) and balloon expulsion test (BET). METHODS Studies were performed in 12 patients before and after 8 weeks of biofeedback training. The Fecal Incontinence Severity Index (FISI) score was obtained. Anal resting and squeeze pressures were measured before the bag was distended in the rectum until urge to defecate. Pressure recordings were made during Fecobionics evacuation. RESULTS BFT resulted in 24% reduction in FISI scores (P < 0.01). Seven patients were characterized as responders. Anal pressures, the urge-to-defecate volume, and defecatory parameters did not change significantly during BFT. For ARM-BET, the maximum anal squeeze pressure, the urge-to-defecate volume, and the expulsion time were lower after BFT compared with those before BFT (P < 0.05). For Fecobionics, the change in urge volume (r = 0.74, P < 0.05) and the change in defecation index (r = 0.79, P < 0.01) were associated with the change in FISI score. None of the ARM-BET parameters were associated with the change in FISI score. It was studied whether any pre-BFT data could predict treatment success. The Fecobionics expulsion duration and the defecation index predicted the outcome (P < 0.05). The defecation index had a sensitivity of 100% and a specificity of 72%. None of the ARM-BET parameters predicted the outcome (all P > 0.2). DISCUSSION Fecobionics was used as a tool to monitor the effect of BFT and proved better than conventional technologies for monitoring and predicting the outcome in the FISI score.
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Affiliation(s)
- Kaori Futaba
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Ssu-Chi Chen
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Wing Wa Leung
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Cherry Wong
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Tony Mak
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Simon Ng
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Hans Gregersen
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
- California Medical Innovations Institute, San Diego, California, USA
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Patel K, Mei L, Yu E, Kern M, Lehal N, Edeani F, Sanvanson P, Davidson ERW, Shaker R. Differences in fatigability of muscles involved in fecal continence: Potential clinical ramifications. Physiol Rep 2021; 9:e15144. [PMID: 34927399 PMCID: PMC8685596 DOI: 10.14814/phy2.15144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 11/19/2021] [Accepted: 11/22/2021] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Fatigue of the anal sphincter complex has been demonstrated using high-resolution anorectal manometry (HRAM). However, the fatigability of individual muscles such as the external anal sphincter (EAS) and puborectalis muscles (PRM) has not been described. Vaginal manometry has been used to study contractile activity of the PRM. By applying both modalities, we attempted to differentiate the fatigability between the PRM and the EAS under different exercise conditions. METHODS We studied two groups: group 1, 12 healthy women (21 ± 2.7 years) with HRAM and group 2, 10 healthy (20 ± 3 years) women with vaginal manometry. All subjects performed 40 repetitive contractions with and without an intra-anal resistive load. In group 1, areas under the curve (AUC) of the anal canal high-pressure zone (HPZ) including the caudal and rostral halves were compared. In group 2, the maximum and mean pressures of the vaginal HPZ were compared. RESULTS The AUC decreased significantly only after repetitive contractions against a resistive load (462 ± 129 vs. 390 ± 131 mmHg-cm, p = 0.02), indicating fatigue. The caudal half (EAS) decreased significantly after contractions against a load (288 ± 75 vs. 239 ± 82 mmHg-cm, p = 0.02), while the rostral half (PRM) did not. The vaginal pressures (PRM) also decreased only after repetitive contractions against a load (maximum pressures, 358 ± 171 vs. 239 ± 109 mmHg, p = 0.02). CONCLUSIONS The EAS and PRM both exhibit fatigue with contractions only against a resistive load. These findings may guide the development of appropriate exercise regimens to target specific muscles involved in fecal continence.
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Affiliation(s)
- Krupa Patel
- Division of Gastroenterology and HepatologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Ling Mei
- Division of Gastroenterology and HepatologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Elliot Yu
- Division of Gastroenterology and HepatologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Mark Kern
- Division of Gastroenterology and HepatologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Navjit Lehal
- Division of Gastroenterology and HepatologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Francis Edeani
- Division of Gastroenterology and HepatologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Patrick Sanvanson
- Division of Gastroenterology and HepatologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Emily R. W. Davidson
- Department of Obstetrics and GynecologyDivision of UrogynecologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Reza Shaker
- Division of Gastroenterology and HepatologyMedical College of WisconsinMilwaukeeWisconsinUSA
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Xiang X, Sharma A, Patcharatrakul T, Yan Y, Karunaratne T, Parr R, Ayyala DN, Hall P, Rao SSC. Randomized controlled trial of home biofeedback therapy versus office biofeedback therapy for fecal incontinence. Neurogastroenterol Motil 2021; 33:e14168. [PMID: 34051120 DOI: 10.1111/nmo.14168] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 03/04/2021] [Accepted: 04/15/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Biofeedback therapy is useful for treatment of fecal incontinence (FI), but is not widely available and labor intensive. We investigated if home biofeedback therapy (HBT) is non-inferior to office biofeedback therapy (OBT). METHODS Patients with FI (≥1 episode/week) were randomized to HBT or OBT for 6 weeks. HBT was performed daily using novel device that provided resistance training and electrical stimulation with voice-guided instructions. OBT consisted of six weekly sessions. Both methods involved anal strength, endurance, and coordination training. Primary outcome was change in weekly FI episodes. FI improvement was assessed with stool diaries, validated instruments (FISI, FISS, and ICIQ-B), and anorectal manometry using intention-to-treat analysis. KEY RESULTS Thirty (F/M = 26/4) FI patients (20 in HBT, 10 in OBT) participated. Weekly FI episodes decreased significantly after HBT (Δ ± 95% confidence interval: 4.7 ± 1.8, compared with baseline, p = 0.003) and OBT (3.7 ± 1.6, p = 0.0003) and HBT was non-inferior to OBT (p = 0.2). The FISI and FISS scores improved significantly in HBT group (p < 0.02). Bowel pattern, bowel control, and quality of life (QOL) domains (ICIQ-B) improved significantly in HBT arm (p < 0.023). Resting and maximum squeeze sphincter pressures significantly improved in both HBT and OBT groups and sustained squeeze pressure in HBT, without group differences. CONCLUSIONS & INFERENCES Home biofeedback therapy is non-inferior to OBT for FI treatment. Home biofeedback is safe, effective, improves QOL, and through increased access could facilitate improved management of FI.
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Affiliation(s)
- Xuelian Xiang
- Division of Gastroenterology & Hepatology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Amol Sharma
- Division of Gastroenterology & Hepatology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Tanisa Patcharatrakul
- Division of Gastroenterology & Hepatology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Yun Yan
- Division of Gastroenterology & Hepatology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Tennekoon Karunaratne
- Division of Gastroenterology & Hepatology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Rachel Parr
- Division of Gastroenterology & Hepatology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Deepak Nag Ayyala
- Department of Population Health Sciences, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Patricia Hall
- Department of Population Health Sciences, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Satish S C Rao
- Division of Gastroenterology & Hepatology, Medical College of Georgia, Augusta University, Augusta, GA, USA
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10
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ACG Clinical Guidelines: Management of Benign Anorectal Disorders. Am J Gastroenterol 2021; 116:1987-2008. [PMID: 34618700 DOI: 10.14309/ajg.0000000000001507] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 08/09/2021] [Indexed: 12/11/2022]
Abstract
Benign anorectal disorders of structure and function are common in clinical practice. These guidelines summarize the preferred approach to the evaluation and management of defecation disorders, proctalgia syndromes, hemorrhoids, anal fissures, and fecal incontinence in adults and represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence for these guidelines was assessed using the Grading of Recommendations Assessment, Development and Evaluation process. When the evidence was not appropriate for Grading of Recommendations Assessment, Development and Evaluation, we used expert consensus to develop key concept statements. These guidelines should be considered as preferred but are not the only approaches to these conditions.
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Rao SSC, Yan Y, Xiang X, Sharma A, Ayyala D, Hamdy S. Effects of Translumbosacral Neuromodulation Therapy on Gut and Brain Interactions and Anorectal Neuropathy in Fecal Incontinence: A Randomized Study. Neuromodulation 2021; 24:1269-1277. [PMID: 34156730 PMCID: PMC8542581 DOI: 10.1111/ner.13485] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/25/2021] [Accepted: 06/01/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Translumbosacral neuromodulation therapy (TNT) improves symptoms of fecal incontinence (FI), but its mechanism of action is unknown. We tested the hypothesis that TNT at one or more frequency will significantly improve underlying pathophysiology of FI through modulation of ascending and/or descending signaling pathways in the gut and brain axis and anorectal sensorimotor function. MATERIALS AND METHODS We assessed afferent anorectal-cortical evoked potentials (CEP) following electrical stimulation of anorectum, efferent cortico-anorectal and lumbo-anorectal and sacro-anorectal motor evoked potentials (MEP) after transcranial and lumbosacral magnetic stimulations, and anorectal manometry before and after six weekly TNT sessions in FI subjects, randomized to 1, 5, or 15 Hz repetitive magnetic stimulations. Neurophysiology, anorectal sensorimotor function, and symptoms were compared to examine mechanistic effects. Co-primary measures were ano-cortical CEPs, cortico-anal MEPs, and lumbosacral-anal MEPs. Baseline and post-treatment data were compared with Wilcoxon signed-rank test and changes between the three frequencies with one-way ANOVA. RESULTS Thirty-three FI patients participated. After TNT, the afferent anal CEP latencies significantly decreased in the 1 Hz group compared to baseline (p = 0.0029) and 5 Hz or 15 Hz groups (p = 0.032). Cortico-anal MEPs were unchanged in all three groups. Bilateral lumbo-anal and sacro-anal MEP latencies significantly decreased with 1 Hz, lumbo-anal with 15 Hz, and sacro-anal with 5 Hz compared to baseline but without group differences. The 1 Hz group showed significant increase in anal squeeze sphincter pressure (p < 0.005) and maximum tolerable volume (p < 0.019) and demonstrated higher FI responder rate (p < 0.04) compared to the other two groups. The MEP responders were significantly correlated with FI responders (p = 0.006) in 1 Hz group. CONCLUSIONS TNT significantly improves afferent ano-cortical signaling, efferent lumbo-anal and sacro-anal neuropathy and anorectal sensorimotor function. These neurobiologic effects were most prominent with 1 Hz frequency. TNT improves FI by modifying the underlying pathophysiology possibly through neuromodulation.
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Affiliation(s)
- Satish S C Rao
- Division of Neurogastroenterology/Motility, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Yun Yan
- Division of Neurogastroenterology/Motility, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Xuelian Xiang
- Division of Neurogastroenterology/Motility, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Amol Sharma
- Division of Neurogastroenterology/Motility, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Deepak Ayyala
- Department of Population Health Sciences, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Shaheen Hamdy
- GI Sciences, School of Medical Sciences, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
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12
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Meyer I, Richter HE. Accidental Bowel Leakage/Fecal Incontinence: Evidence-Based Management. Obstet Gynecol Clin North Am 2021; 48:467-485. [PMID: 34416932 DOI: 10.1016/j.ogc.2021.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Fecal incontinence is a highly prevalent and debilitating condition that negatively impacts quality of life. The etiology is often multifactorial and treatment can be hindered by lack of understanding of its mechanisms and 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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13
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Bharucha AE, Gantz MG, Rao SS, Lowry AC, Chua H, Karunaratne T, Wu J, Hamilton FA, Whitehead WE. Comparative effectiveness of biofeedback and injectable bulking agents for treatment of fecal incontinence: Design and methods. Contemp Clin Trials 2021; 107:106464. [PMID: 34139357 PMCID: PMC8429255 DOI: 10.1016/j.cct.2021.106464] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 05/08/2021] [Accepted: 05/30/2021] [Indexed: 12/13/2022]
Abstract
Fecal incontinence (FI), the involuntary passage of stool, is common and can markedly impair the quality of life. Among patients who fail initial options (pads or protective devices, bowel modifying agents, and pelvic floor exercises), the options are pelvic floor biofeedback (BIO), perianal injection with bulking agents (INJ), and sacral nerve electrical stimulation (SNS), which have not been subjected to head-to-head comparisons. This study will compare the safety and efficacy of BIO and INJ for managing FI. The impact of these approaches on quality-of-life and psychological distress, cost effectiveness, and predictors of response to therapy will also be evaluated. Six centers in the United States will enroll approximately 285 patients with moderate to severe FI. Patients who have 4 or more FI episodes over 2 weeks proceed to a 4-week trial of enhanced medical management (EMM) (ie, education, bowel management, and pelvic floor exercises). Thereafter, 194 non-responders as defined by a less than 75% reduction in the frequency of FI will be randomized to BIO or INJ. Three months later, the efficacy, safety, and cost of therapy will be assessed; non-responders will be invited to choose to add the other treatment or SNS for the remainder of the study. Early EMM responders will be re-evaluated 3 months later and non-responders randomized to BIO or INJ. Standardized, and where appropriate validated approaches will be used for study procedures, which will be performed by trained personnel. Prospectively collected data on care costs and resource utilization will be used for cost effectiveness analyses.
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Affiliation(s)
- Adil E. Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Mn
| | - Marie G. Gantz
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, NC
| | - Satish S. Rao
- Division of Gastroenterology, Augusta University, Augusta, Ga
| | - Ann C. Lowry
- Colon and Rectal Surgery Associates, Minneapolis, Mn
| | - Heidi Chua
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Mn
| | | | - Jennifer Wu
- Division of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC
| | - Frank A. Hamilton
- National Institute of Digestive Diseases, Kidney, and Diabetes, Bethesda, MD
| | - William E. Whitehead
- Center for Functional GI and Motility Disorders, University of North Carolina, Chapel Hill, NC
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14
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Vega M, Mckay ER, Halani PK. Evaluation of mobile applications for patients with fecal incontinence using a modified APPLICATIONS scoring system. Int Urogynecol J 2021; 32:2529-2536. [PMID: 34245316 DOI: 10.1007/s00192-021-04918-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 06/10/2021] [Indexed: 12/17/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Mobile applications (apps) are becoming an increasingly popular means of obtaining medical information. The aim of our study was to identify and evaluate patient-centered fecal incontinence (FI) mobile apps using a modified APPLICATIONS scoring system. METHODS We conducted searches in the Apple App and Google Play stores to identify FI-related mobile apps using search terms reflecting both commonly accepted medical terms as well as colloquial terms used by our patients with FI. Apps that were in English, relevant to FI, patient-centered, and medically accurate were included. Each eligible app was then independently evaluated by the three authors using a modified 17-point APPLICATIONS scoring system. RESULTS We identified 2785 apps upon initial search using FI search terms. Fourteen apps met eligibility criteria for scoring. Most apps were bowel movement trackers (13/14, 93%), of which only three allowed for tracking of FI episodes. Only one (7%) app contained educational information specific to FI. Ten (71%) apps were fully functional at no cost. Thirteen (93%) apps cited literature. Median APPLICATIONS score was 10 (IQR 9-11). "BristolStoolChart," "FreeToBe," and "PoopLog" each received the highest total score of 13. CONCLUSIONS Patient-centered mobile apps that provide FI-specific educational information or allow for FI symptom tracking are scarce. While we did discover some accurate sources of information and means of tracking bowel habits, patients are likely to encounter inaccurate or irrelevant information even when searching for FI-related apps using appropriate terminology. Future app development should include FI-specific symptom tracking and educational information from reputable sources.
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Affiliation(s)
- Marisa Vega
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology and Women's Health, Montefiore Medical Center/Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY, 10461, USA.
| | - Elishia Renee Mckay
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology and Women's Health, Montefiore Medical Center/Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY, 10461, USA
| | - Priyanka Kadam Halani
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology and Women's Health, Montefiore Medical Center/Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY, 10461, USA
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15
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Speer AL, Ren X, McNeill EP, Aziz JM, Muir SM, Marino DI, Dadhich P, Sawant K, Ciccocioppo R, Asthana A, Bitar KN, Orlando G. Bioengineering of the digestive tract: approaching the clinic. Cytotherapy 2021; 23:381-389. [PMID: 33840629 DOI: 10.1016/j.jcyt.2021.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 01/29/2021] [Accepted: 02/08/2021] [Indexed: 12/18/2022]
Abstract
The field of regenerative medicine is developing technologies that, in the near future, will offer alternative approaches to either cure diseases affecting the gastrointestinal tract or slow their progression by leveraging the intrinsic ability of our tissues and organs to repair after damage. This article will succinctly illustrate the three technologies that are closer to clinical translation-namely, human intestinal organoids, sphincter bioengineering and decellularization, whereby the cellular compartment of a given segment of the digestive tract is removed to obtain a scaffold consisting of the extracellular matrix. The latter will be used as a template for the regeneration of a functional organ, whereby the newly generated cellular compartment will be obtained from the patient's own cells. Although clinical application of this technology is approaching, product development challenges are being tackled to warrant safety and efficacy.
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Affiliation(s)
- Allison L Speer
- McGovern Medical School, The University of Texas Health Science Center, Houston, Texas, USA
| | - Xi Ren
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - Eoin P McNeill
- McGovern Medical School, The University of Texas Health Science Center, Houston, Texas, USA
| | - Justine M Aziz
- Wake Forest Baptist Medical Center, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Sean M Muir
- Wake Forest Baptist Medical Center, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Domenica I Marino
- College of Arts and Sciences, Ohio State University, Columbus, Ohio, USA
| | | | - Ketki Sawant
- Cellf Bio LLC, Winston-Salem, North Carolina, USA
| | - Rachele Ciccocioppo
- Department of Medicine, Gastroenterology Unit, Giambattista Rossi University Hospital, University Hospital Integrated Trust of Verona, University of Verona, Verona, Italy
| | - Amish Asthana
- Wake Forest Baptist Medical Center, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Khalil N Bitar
- Wake Forest Baptist Medical Center, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA; Cellf Bio LLC, Winston-Salem, North Carolina, USA
| | - Giuseppe Orlando
- Wake Forest Baptist Medical Center, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.
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16
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Assmann S, Keszthelyi D, Kleijnen J, Kimman M, Anastasiou F, Bradshaw E, Carrington E, Chiarioni G, Maeda Y, Muris J, Pohl D, Rydningen M, Vaizey C, Breukink S. The development of a faecal incontinence core outcome set: an international Delphi study protocol. Int J Colorectal Dis 2021; 36:617-622. [PMID: 33532899 PMCID: PMC7895769 DOI: 10.1007/s00384-021-03865-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/26/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Faecal incontinence (FI) is estimated to affect around 7.7% of people. There is a lack of uniformity in outcome definitions, measurement and reporting in FI studies. Until now, there is no general consensus on which outcomes should be assessed and reported in FI research. This complicates comparison between studies and evidence synthesis, potentially leading to recommendations not evidence-based enough to guide physicians in selecting an FI therapy. A solution for this lack of uniformity in reporting of outcomes is the development of a Core Outcome Set (COS) for FI. This paper describes the protocol for the development of a European COS for FI. METHODS Patient interviews and a systematic review of the literature will be performed to identify patient-, physician- and researcher-oriented outcomes. The outcomes will be categorised using the COMET taxonomy and put forward to a group of patients, physicians (i.e. colorectal surgeons, gastroenterologists and general practitioners) and researchers in a Delphi consensus exercise. This exercise will consist of up to three web-based rounds in which participants will prioritise and condense the list of outcomes, which is expected to result in consensus. A consensus meeting with participants from all stakeholder groups will take place to reach a final agreement on the COS. DISCUSSION This study protocol describes the development of a European COS to improve reliability and consistency of outcome reporting in FI studies, thereby improving evidence synthesis and patient care. TRIAL REGISTRATION This project has been registered in the COMET database on the 1st of April 2020, available at http://www.comet-initiative.org/Studies/Details/1554 . The systematic review has been registered on the PROSPERO database on the 31st of August 2020, available at https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=202020&VersionID=1381336 .
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Affiliation(s)
- Sadé Assmann
- Department of Surgery and Colorectal Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands.
- Division of Gastroenterology-Hepatology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands.
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands.
| | - Daniel Keszthelyi
- Division of Gastroenterology-Hepatology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
| | - Jos Kleijnen
- School for Oncology and Developmental Biology (GROW), Maastricht University, Maastricht, The Netherlands
| | - Merel Kimman
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Foteini Anastasiou
- 4rth TOMY - Academic Primary Care Unit Clinic of Social and Family Medicine, University of Crete, Heraklion, Greece
| | - Elissa Bradshaw
- Community Gastroenterology Specialist Nurse, Royal Free Hospital, London, England
| | - Emma Carrington
- Surgical Professorial Unit, Department of Colorectal Surgery, St Vincent's University Hospital, Dublin, Ireland
| | - Giuseppe Chiarioni
- Division of Gastroenterology of the University of Verona, AOUI Verona, Verona, Italy
- Center for Functional GI and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Yasuko Maeda
- Department of Surgery and Colorectal Surgery, Western General Hospital, Edinburgh, UK
| | - Jean Muris
- Department of General Practice, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Daniel Pohl
- Department of Gastroenterology and Hepatology, University Hospital of Zurich, Zurich, Switzerland
| | - Mona Rydningen
- Department of Gastrointestinal Surgery, University Hospital of North Norway, Tromsø, Norway
- Norwegian National Advisory Unit on Incontinence and Pelvic Floor Health, Tromsø, Norway
| | | | - Stephanie Breukink
- Department of Surgery and Colorectal Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
- School for Oncology and Developmental Biology (GROW), Maastricht University, Maastricht, The Netherlands
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17
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Abstract
Fecal incontinence can be a challenging and stigmatizing disease with a high prevalence in the elderly population. Despite effective treatment options, most patients do not receive care. Clues in the history and physical examination can assist the provider in establishing the diagnosis. Direct inquiry about the presence of incontinence is key. Bowel disturbances are common triggers for symptoms and represent some of the easiest treatment targets. We review the epidemiology and impact of the disease, delineate a diagnostic and treatment approach for primary care physicians to identify patients with suspected fecal incontinence and describe appropriate treatment options.
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Affiliation(s)
- Trisha Pasricha
- Division of Gastroenterology, Massachusetts General Hospital, Wang 5, Boston, MA 02114, USA; Department of Gastroenterology, Massachusetts General Hospital, 165 Cambridge Street, CRP 9, Boston, MA 02114, USA
| | - Kyle Staller
- Division of Gastroenterology, Massachusetts General Hospital, Wang 5, Boston, MA 02114, USA; Department of Gastroenterology, Massachusetts General Hospital, 165 Cambridge Street, CRP 9, Boston, MA 02114, USA.
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18
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Translumbosacral Neuromodulation Therapy for Fecal Incontinence: A Randomized Frequency Response Trial. Am J Gastroenterol 2021; 116:162-170. [PMID: 32740081 PMCID: PMC9455260 DOI: 10.14309/ajg.0000000000000766] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 05/21/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Treatments for fecal incontinence (FI) remain unsatisfactory because they do not remedy the underlying multifactorial dysfunction(s) including anorectal neuropathy. The aim of this study was to investigate the optimal dose frequency, clinical effects, and safety of a novel treatment, translumbosacral neuromodulation therapy (TNT), aimed at improving neuropathy. METHODS Patients with FI were randomized to receive 6 sessions of weekly TNT treatments consisting of 600 repetitive magnetic stimulations over each of 2 lumbar and 2 sacral sites with either 1, 5, or 15 Hz frequency. Stool diaries, FI severity indices, anorectal neurophysiology and sensorimotor function, and quality of life were compared. Primary outcome measure was the change in FI episodes/week. Responders were patients with ≥50% decrease in weekly FI episodes. RESULTS Thirty-three patients with FI participated. FI episodes decreased significantly (∆ ±95% confidence interval, 4.2 ± 2.8 (1 Hz); 2 ± 1.7 (5 Hz); 3.4 ± 2.5 (15 Hz); P < 0.02) in all 3 groups when compared with baseline. The 1 Hz group showed a significantly higher (P = 0.04) responder rate (91 ± 9.1%) when compared with the 5 Hz group (36 ± 18.2%) or 15 Hz (55 ± 18.2%); no difference was found between the 5 and 15 Hz groups (P = 0.667). Anal neuropathy, squeeze pressure, and rectal capacity improved significantly only in the 1 Hz (P < 0.05) group compared with baseline, but not in other groups. Quality of life domains improved significantly (P < 0.05) with 1 and 5 Hz groups. No device-related serious adverse events were noted. DISCUSSION TNT significantly improves FI symptoms in the short term, and the 1 Hz frequency was overall better than 5 and 15 Hz. Both anorectal neuropathy and physiology significantly improved, demonstrating mechanistic improvement. TNT is a promising, novel, safe, efficacious, and noninvasive treatment for FI (see Visual Abstract, Supplementary Digital Content 3, http://links.lww.com/AJG/B598).
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19
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Bharucha AE, Oblizajek NR. Translumbosacral Neuromodulation Therapy Is a Promising Option for Fecal Incontinence. Am J Gastroenterol 2021; 116:80-81. [PMID: 33273260 PMCID: PMC7775327 DOI: 10.14309/ajg.0000000000001069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 10/26/2020] [Indexed: 12/11/2022]
Abstract
ABSTRACT Fecal incontinence is a common symptom that can significantly impair quality of life. The treatment options range from conservative measures (e.g., Kegel exercises, pelvic floor biofeedback therapy, fiber supplementation, or medications) to noninvasive nerve stimulation (e.g., posterior tibial nerve stimulation and transcutaneous tibial nerve stimulation), implanted neurostimulation (i.e., sacral nerve stimulation), perianal injection of dextranomer, and anal sphincteroplasty. In this issue of the journal, a promising, uncontrolled study suggests that noninvasive, repetitive magnetic stimulation of the lumbosacral nerves significantly improved symptoms, increased anal squeeze pressure, and increased rectal compliance in patients with fecal continence. Sham-controlled studies are necessary to confirm these findings.
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Affiliation(s)
- Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
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20
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Abstract
Nine percent of adult women experience episodes of fecal incontinence at least monthly. Fecal incontinence is more common in older women and those with chronic bowel disturbance, diabetes, obesity, prior anal sphincter injury, or urinary incontinence. Fecal incontinence negatively affects quality of life and mental health and is associated with increased risk of nursing home placement. Fewer than 30% of women with fecal incontinence seek care, and lack of information about effective solutions is an important barrier for both patients and health care professionals. Even among women with both urinary and fecal incontinence presenting for urogynecologic care, the rate of verbal disclosure of fecal incontinence symptoms remains low. This article provides an overview of the evaluation and management of fecal incontinence for the busy obstetrician-gynecologist, incorporating existing guidance from the American College of Obstetricians and Gynecologists, the American College of Gastroenterology, and the American Society of Colon and Rectal Surgeons. The initial clinical evaluation of fecal incontinence requires a focused history and physical examination. Recording patient symptoms using a standard diary or questionnaire can help document symptoms and response to treatment. Invasive diagnostic testing and imaging generally are not needed to initiate treatment but may be considered in complex cases. Most women have mild symptoms that will improve with optimized stool consistency and medications. Additional treatment options include pelvic floor muscle strengthening with or without biofeedback, devices placed anally or vaginally, and surgery, including sacral neurostimulation, anal sphincteroplasty, and, for severely affected individuals for whom other interventions fail, colonic diversion.
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Affiliation(s)
- Heidi W Brown
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Kaiser Permanente San Diego, San Diego, California; and the Department of Women's Health, Dell Medical School, University of Texas at Austin, Austin Texas
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21
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Ohara N, Takahashi H, Katsuyama S, Doki Y, Mori M, Nakajima K. Electrical contraction of the anal sphincter for intraoperative visualization of anal function. MINIM INVASIV THER 2020; 31:127-136. [DOI: 10.1080/13645706.2020.1773855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Nobuyoshi Ohara
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Hidekazu Takahashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Shinsuke Katsuyama
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
- Department of Next Generation Endoscopic Intervention (Project ENGINE), Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Masaki Mori
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Kiyokazu Nakajima
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
- Department of Next Generation Endoscopic Intervention (Project ENGINE), Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
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22
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Abstract
Fecal incontinence, or the involuntary leakage of solid or loose stool, is estimated to affect 7-15% of community-dwelling women (1). It is associated with reduced quality of life, negative psychologic effects, and social stigma (2), yet many women do not report their symptoms or seek treatment. Less than 3% of women who do self-report fecal incontinence will have this diagnosis recorded in their medical record (3). Obstetrician-gynecologists are in a unique position to identify women with fecal incontinence because pregnancy, childbirth, obstetric anal sphincter injuries (OASIS), and pelvic floor dysfunction are important risk factors that contribute to fecal incontinence in women. The purpose of this Practice Bulletin is to provide evidence-based guidelines on the screening, evaluation, and management of fecal incontinence to help obstetrician-gynecologists diagnose the condition and provide conservative treatment or referral for further work up and surgical management when appropriate. For discussion on fecal incontinence associated with OASIS, see Practice Bulletin No. 198, Prevention and Management of Obstetric Lacerations at Vaginal Delivery (4).
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23
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Dadhich P, Bohl JL, Tamburrini R, Zakhem E, Scott C, Kock N, Mitchell E, Gilliam J, Bitar KN. BioSphincters to treat Fecal Incontinence in Nonhuman Primates. Sci Rep 2019; 9:18096. [PMID: 31792260 PMCID: PMC6888838 DOI: 10.1038/s41598-019-54440-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 11/12/2019] [Indexed: 02/07/2023] Open
Abstract
Loss of anorectal resting pressure due to internal anal sphincter (IAS) dysfunctionality causes uncontrolled fecal soiling and leads to passive fecal incontinence (FI). The study is focused on immediate and long-term safety and potential efficacy of bioengineered IAS BioSphincters to treat passive FI in a clinically relevant large animal model of passive FI. Passive FI was successfully developed in Non-Human Primates (NHPs) model. The implantation of autologous intrinsically innervated functional constructs resolved the fecal soiling, restored the resting pressure and Recto Anal Inhibitory Reflex (RAIR) within 1-month. These results were sustained with time, and efficacy was preserved up to 12-months. The histological studies validated manometric results with the regeneration of a well-organized neuro-muscular population in IAS. The control groups (non-treated and sham) remained affected by poor anal hygiene, lower resting pressure, and reduced RAIR throughout the study. The pathological assessment of implants, blood, and the vital organs confirmed biocompatibility without any adverse effect after implantation. This regenerative approach of implanting intrinsically innervated IAS BioSphincters has the potential to offer a better quality of life to the patients suffering from FI.
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Affiliation(s)
- Prabhash Dadhich
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston Salem, NC, USA
- Program in Neuro-Gastroenterology and Motility, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Jaime L Bohl
- Department of Surgery, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Riccardo Tamburrini
- Department of Surgery, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Elie Zakhem
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston Salem, NC, USA
- Program in Neuro-Gastroenterology and Motility, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Christie Scott
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Nancy Kock
- Department of Pathology, Section on Comparative Medicine, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Erin Mitchell
- Animal Resources Program, Wake Forest Baptist Health, Winston Salem, NC, USA
| | - John Gilliam
- Section on Gastroenterology, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Khalil N Bitar
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston Salem, NC, USA.
- Program in Neuro-Gastroenterology and Motility, Wake Forest School of Medicine, Winston Salem, NC, USA.
- Section on Gastroenterology, Wake Forest School of Medicine, Winston Salem, NC, USA.
- Virginia Tech-Wake Forest School of Biomedical Engineering and Sciences, Wake Forest School of Medicine, Winston Salem, NC, USA.
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24
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Getting Ready for Continence Certification. J Wound Ostomy Continence Nurs 2019; 46:550-552. [DOI: 10.1097/won.0000000000000584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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25
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Ussing A, Dahn I, Due U, Sørensen M, Petersen J, Bandholm T. Efficacy of Supervised Pelvic Floor Muscle Training and Biofeedback vs Attention-Control Treatment in Adults With Fecal Incontinence. Clin Gastroenterol Hepatol 2019; 17:2253-2261.e4. [PMID: 30580089 DOI: 10.1016/j.cgh.2018.12.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 12/05/2018] [Accepted: 12/11/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Pelvic floor muscle training (PFMT) in combination with conservative treatment is recommended as first-line treatment for patients with fecal incontinence, although its efficacy is unclear. We investigated whether supervised PFMT in combination with conservative treatment is superior to attention-control massage treatment and conservative treatment in adults with fecal incontinence. METHODS We performed a randomized, controlled, superiority trial of patients with fecal incontinence at a tertiary care center at a public hospital in Denmark. Ninety-eight adults with fecal incontinence were randomly assigned to groups that received supervised PFMT and biofeedback plus conservative treatment or attention-control treatment plus conservative treatment. The primary outcome was rating of symptom changes, after 16 weeks, based on scores from the Patient Global Impression of Improvement scale. Secondary outcomes were changes in the Vaizey incontinence score (Vaizey Score), Fecal Incontinence Severity Index, and Fecal Incontinence Quality of Life Scale. RESULTS In the intention-to-treat analysis, participants in the PFMT group were significantly more likely to report improvement in incontinence symptoms based on Patient Global Impression of Improvement scale scores (unadjusted odds ratio, 5.16; 95% CI, 2.18-12.19; P = .0002). The PFMT group had a larger reduction in the mean Vaizey Score (reduction, -1.83 points; 95% CI, -3.57 to -0.08; P = .04). There were no significant differences in condition-specific quality of life. In the per-protocol analyses, the superiority of PFMT was increased. No adverse events were reported. CONCLUSIONS This randomized controlled trial of adults with fecal incontinence provides support for a superior effect of supervised PFMT in combination with conservative treatment compared with attention-control massage treatment and conservative treatment. We found that participants who received supervised PFMT had 5-fold higher odds of reporting improvements in fecal incontinence symptoms and had a larger mean reduction of incontinence severity based on the Vaizey Score compared with attention control massage treatment. Clinicaltrials.gov no: NCT01705535.
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Affiliation(s)
- Anja Ussing
- Department of Physiotherapy and Occupational Therapy, Herlev, Denmark; Optimed, Clinical Research Centre, Herlev, Denmark.
| | - Inge Dahn
- Department of Surgical and Medical Gastroenterology, Herlev, Denmark
| | - Ulla Due
- Department of Obstetrics and Gynaecology, Herlev, Denmark; Department of Occupational and Physical Therapy, Herlev Hospital, Herlev, Denmark
| | - Michael Sørensen
- Department of Surgical and Medical Gastroenterology, Herlev, Denmark
| | - Janne Petersen
- Optimed, Clinical Research Centre, Herlev, Denmark; Section of Biostatistics, Department of Public Health, Herlev, Denmark
| | - Thomas Bandholm
- Department of Physiotherapy and Occupational Therapy, Herlev, Denmark; Optimed, Clinical Research Centre, Herlev, Denmark; Physical Medicine and Rehabilitation Research-Copenhagen, Copenhagen University Hospital, Hvidovre, Denmark
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Richter HE, Dunivan G, Brown HW, Andy U, Dyer KY, Rardin C, Muir T, McNevin S, Paquette I, Gutman RE, Quiroz L, Wu J. A 12-Month Clinical Durability of Effectiveness and Safety Evaluation of a Vaginal Bowel Control System for the Nonsurgical Treatment of Fecal Incontinence. Female Pelvic Med Reconstr Surg 2019; 25:113-119. [PMID: 30807411 DOI: 10.1097/spv.0000000000000681] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The aim of this study was to characterize clinical success, impact on quality of life, and durability up to 1 year in women with fecal incontinence (FI) responsive to an initial test period with a trial vaginal bowel control system. METHODS This was a prospective open-label study in subjects with FI and successfully fit who underwent an initial 2-week trial period. Those achieving 50% or greater reduction in FI episodes were provided the long-term system. Primary outcome was success at 3 months defined as 50% or greater reduction in baseline FI episodes, also assessed at 6 and 12 months. Secondary outcomes included symptom impact measured with Fecal Incontinence Quality of Life scale, symptom severity by the St Mark's (Vaizey) questionnaire, Patient Global Impression of Improvement, and satisfaction. Adverse events were collected. Primary analysis was intention to treat (ITT). RESULTS Seventy-three subjects with baseline mean of 14.1 ± 12.15 FI episodes over 2 weeks entered the treatment period. Success rate at 3 months was 72.6% (53/73, P < 0.0001); per-protocol, 84.1% (53/63, P < 0.0001). Significant improvement in all Fecal Incontinence Quality of Life subscales and St Mark's questionnaire meeting minimally important differences was noted. Satisfaction was 91.7%, 89.7%, and 94.4% at 3, 6, and 12 months, respectively; 77.4%, 77.6%, and 79.6% were very much/much better on the Patient Global Impression of Improvement at 3, 6, and 12 months, respectively. Most common adverse event was vaginal wall injury, with most adverse events (90/134, 67%) occurring during fitting period. CONCLUSIONS In women with successful fitting and initial treatment response, durable efficacy was seen at 3, 6, and 12 months by objective and subjective measures, with favorable safety.
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Affiliation(s)
| | | | - Heidi W Brown
- University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI
| | - Uduak Andy
- University of Pennsylvania, Philadelphia, PA
| | | | | | | | | | | | - Robert E Gutman
- MedStar Washington Hospital Center/Georgetown University, Washington, DC
| | | | - Jennifer Wu
- University of North Carolina, Chapel Hill, NC
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Abstract
PURPOSE OF REVIEW Biofeedback therapy (BFT) is effective for managing pelvic floor disorders (i.e., defecatory disorders and fecal incontinence). However, even in controlled clinical trials, only approximately 60% of patients with defecatory disorders experienced long-term improvement. The review serves to update practitioners on recent advances and to identify practical obstacles to providing biofeedback therapy. RECENT FINDINGS The efficacy and safety of biofeedback therapy have been evaluated in defecatory disorders, fecal incontinence, and levator ani syndrome. Recent studies looked at outcomes in specific patient sub-populations and predictors of a response to biofeedback therapy. Biofeedback therapy is effective for managing defecatory disorders, fecal incontinence, and levator ani syndrome. Patients who have a lower bowel satisfaction score and use digital maneuvers fare better. Biofeedback therapy is recommended for patients with fecal incontinence who do not respond to conservative management. A subset of patients with levator ani syndrome who have dyssynergic defecation are more likely to respond to biofeedback therapy.
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28
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Bocchini R, Chiarioni G, Corazziari E, Pucciani F, Torresan F, Alduini P, Bassotti G, Battaglia E, Ferrarini F, Galeazzi F, Londoni C, Rossitti P, Usai Satta P, Iona L, Marchi S, Milazzo G, Altomare DF, Barbera R, Bove A, Calcara C, D'Alba L, De Bona M, Goffredo F, Manfredi G, Naldini G, Neri MC, Turco L, La Torre F, D'Urso AP, Berni I, Balestri MA, Busin N, Boemo C, Bellini M. Pelvic floor rehabilitation for defecation disorders. Tech Coloproctol 2019; 23:101-115. [PMID: 30631977 DOI: 10.1007/s10151-018-1921-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 12/26/2018] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- R Bocchini
- Gastroenterology Unit, Malatesta Novello Private Hospital, Cesena, Italy.
| | - G Chiarioni
- RFF Division of Gastroenterology, University of Verona, Verona, Italy.,Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - E Corazziari
- Department of Gastroenterology, Istituto Clinico Humanitas, Milan, Italy
| | - F Pucciani
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - F Torresan
- Department of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - P Alduini
- Gastroenterology and Endoscopy Unit, San Luca Hospital, Lucca, Italy
| | - G Bassotti
- Gastroenterology and Hepatology Section, Department of Medicine, University of Perugia Medical School, Perugia, Italy
| | - E Battaglia
- Gastroenterology and Endoscopy Unit, Cardinal Massaia Hospital, Asti, Italy
| | - F Ferrarini
- Endoscopy Unit, San Clemente Private Hospital, Mantua, Italy
| | - F Galeazzi
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - C Londoni
- Gastroenterology and Endoscopy Unit, ASST "Maggiore", Crema, Cremona, Italy
| | - P Rossitti
- Gastroenterology Unit, S. Maria della Misericordia Hospital, Udine, Italy
| | - P Usai Satta
- Gastroenterology Unit, G. Brotzu Hospital, Cagliari, Italy
| | - L Iona
- Early Rehabilitation Department, S. Maria della Misericordia Hospital, Udine, Italy
| | - S Marchi
- Gastrointestinal Unit, Departmentt. of General Surgery, University of Pisa, Pisa, Italy
| | - G Milazzo
- U.O.Lungodegenza e Medicina, Ospedale Vittorio Emanuele III, Salemi, Tp, Italy
| | - D F Altomare
- Department of Emergency and Organ Transplantation (DETO) and Interdepart mental Research Center for Pelvic Floor Dysfunction (CIRPAP), University Aldo Moro, Policlinico, Bari, Italy
| | - R Barbera
- San Giuseppe Multimedica Hospital, Milan, Italy
| | - A Bove
- Gastroenterology and Endoscopy Unit, Department of Gastroenterology, A. Cardarelli Hospital, Naples, Italy
| | - C Calcara
- Gastroenterology Unit, SSVD Gastroenterologia, Ospedale SS Trinità, Borgomanero, No, Italy
| | - L D'Alba
- Gastroenterology and Digestive Endoscopy Unit, San Giovanni-Addolorata Hospital, Rome, Italy
| | - M De Bona
- Gastroenterology and Endoscopy Unit, Feltre Hospital, Feltre, Bl, Italy
| | - F Goffredo
- Gastroenterology and Endoscopy Unit, San Camillo-Forlanini Hospital, Rome, Italy
| | - G Manfredi
- Department of Gastroenterology and Digestive Endoscopy, Crema Hospital, ASST CREMA, Crema, Italy
| | - G Naldini
- Proctological and Perineal Surgery Unit, Cisanello University Hospital, Pisa, Italy
| | - M C Neri
- Gastroenterology Unit, Geriatric Institute "Pio Albergo Trivulzio", Milan, Italy
| | - L Turco
- Department of Digestive Physiopathology, Healte Center "Cittadella della Salute", Lecce, Italy
| | - F La Torre
- Department of Surgical Sciences, University "La Sapienza", Policlinico Umberto I, Rome, Italy
| | | | - I Berni
- Rehabilitation Department, San Luca Hospital, Lucca, Italy
| | - M A Balestri
- Proctological and Perineal Surgery Unit, Cisanello University Hospital, Pisa, Italy
| | - N Busin
- Rehabilitation Department, Villa Igea Private Hospital, Forlì, Italy
| | - C Boemo
- Early Rehabilitation Department, S. Maria della Misericordia Hospital, Udine, Italy
| | - M Bellini
- Gastrointestinal Unit, Department of General Surgery, University of Pisa, Pisa, Italy
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29
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The Quality of Health Information Available on the Internet for Patients With Fecal Incontinence. Female Pelvic Med Reconstr Surg 2019; 25:120-124. [DOI: 10.1097/spv.0000000000000658] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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30
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Physical Activity, BMI, and Risk of Fecal Incontinence in the Nurses' Health Study. Clin Transl Gastroenterol 2018; 9:200. [PMID: 30356052 PMCID: PMC6200735 DOI: 10.1038/s41424-018-0068-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 09/04/2018] [Accepted: 09/22/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Higher body mass index (BMI) and low physical activity have been associated with increased prevalence of fecal incontinence (FI) in cross-sectional studies, but prospective studies examining the role of these factors are lacking. We sought to determine whether BMI and/or physical activity are associated with risk of FI among older women. METHODS We prospectively examined the association between BMI and physical activity and risk of FI in the Nurses' Health Study among 51,708 women who were free of FI in 2008. We defined FI as at ≥1 liquid or solid FI episode/month during the past year reported in 2010 or 2012. We used Cox proportional hazards models to calculate multivariable-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for FI according to physical activity and BMI, adjusting for potential confounding factors. RESULTS During more than 175,000 person-years of follow-up, we documented 5954 cases of incident FI. Compared with women in the lowest activity category (<3 metabolic equivalent of task (MET)-hrs/week), multivariable-adjusted HRs for FI were 0.86 (95% CI 0.80-0.93) for women doing 3-8 MET-hrs/week, 0.78 (95% CI 0.72-0.84) for 9-17 MET-hrs/week, 0.76 (95% CI 0.69-0.83) for 18-26 MET-hrs/week, and 0.75 (95% CI 0.70-0.81) for 27 + MET-hrs/week (Ptrend = <0.0001). There was no association between BMI and risk of FI. CONCLUSIONS Higher levels of physical activity were associated with a modest reduction (25%) in risk of incident FI among older women. These results support a potential role of ongoing physical activity in the neuromuscular health of the anorectal continence mechanism with aging. TRANSLATIONAL IMPACT These results support a potential role of ongoing physical activity in the neuromuscular health of the anorectal continence mechanism with aging.
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31
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Chen Y, Liu Y, Sarker MMR, Yan X, Yang C, Zhao L, Lv X, Liu B, Zhao C. Structural characterization and antidiabetic potential of a novel heteropolysaccharide from Grifola frondosa via IRS1/PI3K-JNK signaling pathways. Carbohydr Polym 2018; 198:452-461. [DOI: 10.1016/j.carbpol.2018.06.077] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 06/11/2018] [Accepted: 06/16/2018] [Indexed: 12/18/2022]
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Staller K, Song M, Grodstein F, Whitehead WE, Matthews CA, Kuo B, Chan AT. Increased Long-term Dietary Fiber Intake Is Associated With a Decreased Risk of Fecal Incontinence in Older Women. Gastroenterology 2018; 155:661-667.e1. [PMID: 29758215 DOI: 10.1053/j.gastro.2018.05.021] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 05/01/2018] [Accepted: 05/07/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS Fiber supplements are frequently used as treatment for fecal incontinence (FI), but little is known about the role of dietary fiber in the prevention of FI. METHODS We performed a prospective study to examine the association between long-term dietary fiber intake and risk of FI in 58,330 older women (mean age, 73 years) in the Nurses' Health Study who were free of FI in 2008. Energy-adjusted long-term dietary fiber intake was determined using food frequency questionnaires starting in 1984 and updated through 2006. We defined incident FI as at least 1 liquid or solid FI episode per month during the past year during 4 years of follow-up using self-administered biennial questionnaires. We used Cox proportional hazards models to calculate multivariable-adjusted hazard ratios and 95% CIs for FI according to fiber intake, adjusting for potential confounding factors. RESULTS During 193,655 person-years of follow-up, we documented 7,056 incident cases of FI. Compared with women in the lowest quintile of fiber intake (13.5 g/day), women in the highest quintile (25 g/day) had an 18% decrease in risk of FI (multivariable hazard ratio, 0.82; 95% CI, 0.76-0.89). This decrease appeared to be greatest for risk of liquid stool FI, which was 31% lower in women with the highest intake of fiber compared with women with the lowest intake (multivariable hazard ratio, 0.69; 95% CI, 0.62-0.75). Risk of FI was not significantly associated with fiber source. CONCLUSIONS In an analysis of data from almost 60,000 older women in the Nurses' Health Study, we found higher long-term intake of dietary fiber was associated with decreased risk of FI. Further studies are needed to determine the mechanisms that mediate this association.
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Affiliation(s)
- Kyle Staller
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School Boston, Massachusetts; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts; Center for Neurointestinal Health, Massachusetts General Hospital, Boston, Massachusetts.
| | - Mingyang Song
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts
| | - Francine Grodstein
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - William E Whitehead
- Center for Functional Gastrointestinal and Motility Disorders and Division of Gastroenterology and Hepatology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Catherine A Matthews
- Department of Urology and Obstetrics and Gynecology, Wake Forest University Medical Center, Winston-Salem, North Carolina
| | - Braden Kuo
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School Boston, Massachusetts; Center for Neurointestinal Health, Massachusetts General Hospital, Boston, Massachusetts
| | - Andrew T Chan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School Boston, Massachusetts; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts
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33
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Abstract
PURPOSE OF REVIEW The purpose of this review is to highlight current and newer therapeutic approaches to treat fecal incontinence in patients who do not respond to conservative measures. RECENT FINDINGS Neurostimulation techniques, injection of bulking agents, and radiofrequency energy delivery to the anal canal have been proposed and tested for fecal incontinence over the last decade. Sacral stimulation is both effective and durable and is now the most popular of the invasive techniques whereas percutaneous tibial stimulation, radiofrequency energy, and bulking agents are either less effective or their evaluation has been handicapped by suboptimal study designs. The precise indications for the new vaginal control device and anal plugs remain to be established. The magnetic anal sphincter is disappointing. Stem cell therapy is a potentially exciting approach, which is in its infancy. There continues to be an unmet need for innovative approaches to patients with fecal incontinence who do not respond to conservative measures. The efficacy of current and future therapies should be assessed using criteria more stringent than has been used in the past to provide a more realistic assessment of meaningful efficacy.
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Meldgaard T, Olesen SS, Farmer AD, Krogh K, Wendel AA, Brock B, Drewes AM, Brock C. Diabetic Enteropathy: From Molecule to Mechanism-Based Treatment. J Diabetes Res 2018; 2018:3827301. [PMID: 30306092 PMCID: PMC6165592 DOI: 10.1155/2018/3827301] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 08/13/2018] [Indexed: 12/19/2022] Open
Abstract
The incidence of the micro- and macrovascular complications of diabetes is rising, mirroring the increase in the worldwide prevalence. Arguably, the most common microvascular complication is neuropathy, leading to deleterious changes in both the structure and function of neurons. Amongst the various neuropathies with the highest symptom burden are those associated with alterations in the enteric nervous system, referred to as diabetic enteropathy. The primary aim of this review is to provide a contemporaneous summary of pathophysiology of diabetic enteropathy thereby allowing a "molecule to mechanism" approach to treatment, which will include 4 distinct aspects. Firstly, the aim is to provide an overview of the diabetes-induced structural remodelling, biochemical dysfunction, immune-mediated alterations, and inflammatory properties of the enteric nervous system and associated structures. Secondly, the aim is to provide a synopsis of the clinical relevance of diabetic enteropathy. Thirdly, the aim is to discuss the various patient-reported outcome measures and the objective modalities for evaluating dysmotility, and finally, the aim is to outline the clinical management and different treatment options that are available. Given the burden of disease that diabetic enteropathy causes, earlier recognition is needed allowing prompt investigation and intervention, which may lead to improvements in quality of life for sufferers.
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Affiliation(s)
- Theresa Meldgaard
- Mech-Sense, Department of Clinical Medicine, Aalborg University, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Mølleparkvej 4, 9000 Aalborg, Denmark
| | - Søren Schou Olesen
- Mech-Sense, Department of Clinical Medicine, Aalborg University, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Mølleparkvej 4, 9000 Aalborg, Denmark
| | - Adam D. Farmer
- Centre for Digestive Diseases, Blizard Institute of Cell & Molecular Science, Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, 4 Newark Street, London E1 2AT, UK
- Department of Gastroenterology, University Hospitals of North Midlands, Stoke-on-Trent, Staffordshire ST4 6QJ, UK
| | - Klaus Krogh
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul Jensens Boulevard, 8200 Aarhus N, Denmark
| | - Anne Astrid Wendel
- Mech-Sense, Department of Clinical Medicine, Aalborg University, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Mølleparkvej 4, 9000 Aalborg, Denmark
| | - Birgitte Brock
- Steno Diabetes Center Copenhagen, The Capital Region of Denmark, Niels Steensens Vej 2-4, Building: NSK, 2820 Gentofte, Denmark
| | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Clinical Medicine, Aalborg University, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Mølleparkvej 4, 9000 Aalborg, Denmark
| | - Christina Brock
- Mech-Sense, Department of Clinical Medicine, Aalborg University, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Mølleparkvej 4, 9000 Aalborg, Denmark
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Bharucha AE, Rao SSC, Shin AS. Surgical Interventions and the Use of Device-Aided Therapy for the Treatment of Fecal Incontinence and Defecatory Disorders. Clin Gastroenterol Hepatol 2017; 15:1844-1854. [PMID: 28838787 PMCID: PMC5693715 DOI: 10.1016/j.cgh.2017.08.023] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 08/07/2017] [Accepted: 08/17/2017] [Indexed: 12/13/2022]
Abstract
The purpose of this clinical practice update expert review is to describe the key principles in the use of surgical interventions and device-aided therapy for managing fecal incontinence (FI) and defecatory disorders. The best practices outlined in this review are based on relevant publications, including systematic reviews and expert opinion (when applicable). Best Practice Advice 1: A stepwise approach should be followed for management of FI. Conservative therapies (diet, fluids, techniques to improve evacuation, a bowel training program, management of diarrhea and constipation with diet and medications if necessary) will benefit approximately 25% of patients and should be tried first. Best Practice Advice 2: Pelvic floor retraining with biofeedback therapy is recommended for patients with FI who do not respond to the conservative measures indicated above. Best Practice Advice 3: Perianal bulking agents such as intra-anal injection of dextranomer may be considered when conservative measures and biofeedback therapy fail. Best Practice Advice 4: Sacral nerve stimulation should be considered for patients with moderate or severe FI in whom symptoms have not responded after a 3-month or longer trial of conservative measures and biofeedback therapy and who do not have contraindications to these procedures. Best Practice Advice 5: Until further evidence is available, percutaneous tibial nerve stimulation should not be used for managing FI in clinical practice. Best Practice Advice 6: Barrier devices should be offered to patients who have failed conservative or surgical therapy, or in those who have failed conservative therapy who do not want or are not eligible for more invasive interventions. Best Practice Advice 7: Anal sphincter repair (sphincteroplasty) should be considered in postpartum women with FI and in patients with recent sphincter injuries. In patients who present later with symptoms of FI unresponsive to conservative and biofeedback therapy and evidence of sphincter damage, sphincteroplasty may be considered when perianal bulking injection and sacral nerve stimulation are not available or have proven unsuccessful. Best Practice Advice 8: The artificial anal sphincter, dynamic graciloplasty, may be considered for patients with medically refractory severe FI who have failed treatment or are not candidates for barrier devices, sacral nerve stimulation, perianal bulking injection, sphincteroplasty and a colostomy. Best Practice Advice 9: Major anatomic defects (eg, rectovaginal fistula, full-thickness rectal prolapse, fistula in ano, or cloaca-like deformity) should be rectified with surgery. Best Practice Advice 10: A colostomy should be considered in patients with severe FI who have failed conservative treatment and have failed or are not candidates for barrier devices, minimally invasive surgical interventions, and sphincteroplasty. Best Practice Advice 11: A magnetic anal sphincter device may be considered for patients with medically refractory severe FI who have failed or are not candidates for barrier devices, perianal bulking injection, sacral nerve stimulation, sphincteroplasty, or a colostomy. Data regarding efficacy are limited and 40% of patients had moderate or severe complications. Best Practice Advice 12: For defecatory disorders, biofeedback therapy is the treatment of choice. Best Practice Advice 13: Based on limited evidence, sacral nerve stimulation should not be used for managing defecatory disorders in clinical practice. Best Practice Advice 14: Anterograde colonic enemas are not effective in the long term for management of defecatory disorders. Best Practice Advice 15: The stapled transanal rectal resection and related procedures should not be routinely performed for correction of structural abnormalities in patients with defecatory disorders.
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Affiliation(s)
- Adil E Bharucha
- Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Division of Gastroenterology and Hepatology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
| | - Satish S C Rao
- Division of Gastroenterology/Hepatology, Department of Internal Medicine, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Andrea S Shin
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana.
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Weledji EP. Electrophysiological Basis of Fecal Incontinence and Its Implications for Treatment. Ann Coloproctol 2017; 33:161-168. [PMID: 29159162 PMCID: PMC5683965 DOI: 10.3393/ac.2017.33.5.161] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 03/30/2017] [Indexed: 12/13/2022] Open
Abstract
The majority of patients with neuropathic incontinence and other pelvic floor conditions associated with straining at stool have damage to the pudendal nerves distal to the ischial spine. Sacral nerve stimulation appears to be a promising innovation and has been widely adopted and currently considered the standard of care for adults with moderate to severe fecal incontinence and following failed sphincter repair. From a decision-to-treat perspective, the short-term efficacy is good (70%-80%), but the long-term efficacy of sacral nerve stimulation is around 50%. Newer electrophysiological tests and improved anal endosonography would more effectively guide clinical decision making.
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Affiliation(s)
- Elroy Patrick Weledji
- Department of Surgery and Obstetrics and Gynecology, Faculty of Health Sciences, University of Buea, Buea, Cameroon
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38
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Ussing A, Dahn I, Due U, Sørensen M, Petersen J, Bandholm T. Supervised pelvic floor muscle training versus attention-control massage treatment in patients with faecal incontinence: Statistical analysis plan for a randomised controlled trial. Contemp Clin Trials Commun 2017; 8:192-202. [PMID: 29696209 PMCID: PMC5898528 DOI: 10.1016/j.conctc.2017.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 07/12/2017] [Accepted: 07/20/2017] [Indexed: 02/06/2023] Open
Abstract
Introduction Faecal incontinence affects approximately 8–9% of the adult population. The condition is surrounded by taboo; it can have a devastating impact on quality of life and lead to major limitations in daily life. Pelvic floor muscle training in combination with information and fibre supplements is recommended as first-line treatment for faecal incontinence. Despite this, the effect of pelvic floor muscle training for faecal incontinence is unclear. No previous trials have investigated the efficacy of supervised pelvic floor muscle training in combination with conservative treatment and compared this to an attention-control massage treatment including conservative treatment. The aim of this trial is to investigate if 16 weeks of supervised pelvic floor muscle training in combination with conservative treatment is superior to attention-control massage treatment and conservative treatment in patients with faecal incontinence. Design Randomised, controlled, superiority trial with two parallel arms. Methods 100 participants with faecal incontinence will be randomised to either (1) individually supervised pelvic floor muscle training and conservative treatment or (2) attention-control massage treatment and conservative treatment. The primary outcome is participants' rating of symptom changes after 16 weeks of treatment using the Patient Global Impression of Improvement Scale. Secondary outcomes are the Vaizey Incontinence Score, the Fecal Incontinence Severity Index, the Fecal Incontinence Quality of Life Scale, a 14-day bowel diary, anorectal manometry and rectal capacity measurements. Follow-up assessment at 36 months will be conducted. Discussion This paper describes and discusses the rationale, the methods and in particular the statistical analysis plan of this trial.
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Affiliation(s)
- Anja Ussing
- Department of Physiotherapy-and Occupational Therapy, Copenhagen University Hospital, Hvidovre, Kettegaards Allé 30, DK-2650 Hvidovre, Denmark.,Optimed, Clinical Research Center, Copenhagen University Hospital, Hvidovre, Kettegaards Allé 30, DK-2650 Hvidovre, Denmark
| | - Inge Dahn
- Department of Surgical and Medical Gastroenterology, Copenhagen University Hospital, Hvidovre, Kettegaards Allé 30, DK-2650 Hvidovre, Denmark
| | - Ulla Due
- Department of Obstetrics and Gynaecology, Herlev Hospital, Herlev Ringvej 75, DK-2730 Herlev, Denmark.,Department of Occupational and Physical Therapy, Herlev Hospital, Herlev Ringvej 75, DK-2730 Herlev, Denmark
| | - Michael Sørensen
- Department of Surgical and Medical Gastroenterology, Copenhagen University Hospital, Hvidovre, Kettegaards Allé 30, DK-2650 Hvidovre, Denmark
| | - Janne Petersen
- Optimed, Clinical Research Center, Copenhagen University Hospital, Hvidovre, Kettegaards Allé 30, DK-2650 Hvidovre, Denmark
| | - Thomas Bandholm
- Department of Physiotherapy-and Occupational Therapy, Copenhagen University Hospital, Hvidovre, Kettegaards Allé 30, DK-2650 Hvidovre, Denmark.,Optimed, Clinical Research Center, Copenhagen University Hospital, Hvidovre, Kettegaards Allé 30, DK-2650 Hvidovre, Denmark.,Physical Medicine & Rehabilitation Research - Copenhagen (PMR-C), Copenhagen University Hospital, Hvidovre, Kettegaards Allé 30, DK-2650 Hvidovre, Denmark
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Vasant DH, Solanki K, Balakrishnan S, Radhakrishnan NV. Integrated low-intensity biofeedback therapy in fecal incontinence: evidence that "good" in-home anal sphincter exercise practice makes perfect. Neurogastroenterol Motil 2017; 29. [PMID: 27440584 DOI: 10.1111/nmo.12912] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Accepted: 06/24/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Biofeedback therapy (BFT) is an established treatment for fecal incontinence (FI), with access often being restricted to tertiary centers due to resources and the perceived requirement for high-intensity regimes. However, the optimal regime remains unknown. We evaluated outcomes from our low-intensity integrated BFT program in a secondary care center. METHODS Outcomes of our BFT service for FI were evaluated retrospectively. Response was defined by ≥50% improvement in FI frequency from baseline or complete continence. Responders were compared to non-responders for factors including symptoms, manometry data, sphincter exercise technique and duration of practice, and the number and frequency of sessions. Where patients dropped out, outcomes and the reason for dropout were obtained retrospectively. KEY RESULTS Fecal incontinence patients (n=205, median 62 years, 72% female) attended a median (IQR) 3 (2) BFT sessions with 55 (36) days between visits. Overall, 146/205 (71%) responded with 97/205 (47%) achieving continence. Fecal incontinence frequency improved dramatically in completed cases (P=0.000). While non-response was associated with males (P=0.03) and dropout (P=0.000), "good" anal sphincter exercise technique (P=0.008) and longer in-home practice (P=0.007) and more sessions (P=0.04) were associated with response. Dropout rate was 80/205 (39%), with the reason for dropout being obtained in 80%. CONCLUSIONS & INFERENCES Despite low-intensity BFT, comparable outcomes to data from tertiary centers were achieved. Our data emphasize the importance of technique and in-home practice of anal sphincter exercises. Customizing BFT intensity based on predictive factors and encouraging in-home practice may optimize outcomes, reduce dropout rates, and rationalize resources.
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Affiliation(s)
- D H Vasant
- GI Physiology and Gastroenterology Departments, Pennine Acute Hospitals NHS Trust, Greater Manchester, UK.,Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - K Solanki
- GI Physiology and Gastroenterology Departments, Pennine Acute Hospitals NHS Trust, Greater Manchester, UK
| | - S Balakrishnan
- GI Physiology and Gastroenterology Departments, Pennine Acute Hospitals NHS Trust, Greater Manchester, UK
| | - N V Radhakrishnan
- GI Physiology and Gastroenterology Departments, Pennine Acute Hospitals NHS Trust, Greater Manchester, UK
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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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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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Peng Y, He J, Khavari R, Boone TB, Zhang Y. Functional mapping of the pelvic floor and sphincter muscles from high-density surface EMG recordings. Int Urogynecol J 2016; 27:1689-1696. [PMID: 27193113 PMCID: PMC5519819 DOI: 10.1007/s00192-016-3026-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 04/11/2016] [Indexed: 12/17/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Knowledge of the innervation of pelvic floor and sphincter muscles is of great importance to understanding the pathophysiology of female pelvic floor dysfunctions. This report presents our high-density intravaginal and intrarectal electromyography (EMG) probes and a comprehensive innervation zone (IZ) imaging technique based on high-density EMG readings to characterize the IZ distribution. METHODS Both intravaginal and intrarectal probes are covered with a high-density surface electromyography electrode grid (8 × 8). Surface EMG signals were acquired in ten healthy women performing maximum voluntary contractions of their pelvic floor. EMG decomposition was performed to separate motor-unit action potentials (MUAPs) and then localize their IZs. RESULTS High-density surface EMG signals were successfully acquired over the vaginal and rectal surfaces. The propagation patterns of muscle activity were clearly visualized for multiple muscle groups of the pelvic floor and anal sphincter. During each contraction, up to 218 and 456 repetitions of motor units were detected by the vaginal and rectal probes, respectively. MUAPs were separated with their IZs identified at various orientations and depths. CONCLUSIONS The proposed probes are capable of providing a comprehensive mapping of IZs of the pelvic floor and sphincter muscles. They can be employed as diagnostic and preventative tools in clinical practices.
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Affiliation(s)
- Yun Peng
- Department of Biomedical Engineering, Cullen College of Engineering, University of Houston, 360 HBS Building, 4811 Calhoun Rd., Houston, TX, 77004, USA
| | - Jinbao He
- School of Electronic and Information Engineering, Ningbo University of Technology, Ningbo, China
| | - Rose Khavari
- Department of Urology, Houston Methodist Hospital and Research Institute, Houston, TX, 77030, USA
| | - Timothy B Boone
- Department of Urology, Houston Methodist Hospital and Research Institute, Houston, TX, 77030, USA
| | - Yingchun Zhang
- Department of Biomedical Engineering, Cullen College of Engineering, University of Houston, 360 HBS Building, 4811 Calhoun Rd., Houston, TX, 77004, USA.
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Rao SSC. Endpoints for therapeutic interventions in faecal incontinence: small step or game changer. Neurogastroenterol Motil 2016; 28:1123-33. [PMID: 27440495 PMCID: PMC4968878 DOI: 10.1111/nmo.12905] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 06/20/2016] [Indexed: 12/15/2022]
Abstract
Faecal incontinence (FI) is common and its pathophysiology and treatments continue to evolve. However, a standard measure(s) for assessing its clinical outcome has been elusive. Consequently, over 100 measures and scoring systems, each with intrinsic biases have been reported. These include adequate relief or global satisfaction, ≥50% reduction in episodes or days without FI, quality of life (QOL), FI severity scales and composite indices. Earlier scales relied on the frequency and type of solid, liquid or flatus incontinence and effects on life style whereas newer scales have incorporated urgency, use of pads, antidiarrhoeals and amount of leakage, using prospective daily stool diaries or retrospective weekly or single point assessments. Such a plethora of measures have negatively impacted the assessment and outcome of clinical trials, and have made comparisons difficult. So, how does one sort out the grain from the chaff? In a provocative, post-hoc analysis published in this issue, the minimal clinically important difference, i.e. the smallest change detected by an instrument that is associated with a clinically meaningful change was used to assess FI endpoint. Based on this a ≥50% reduction in FI episodes is recommended as a clinically meaningful outcome measure when assessed by prospective stool diary, and it correlates with symptoms and severity. However, this requires further validation in multi-centre, longer duration and therapeutically effective clinical trial(s). Simultaneous assessment of coping strategies, QOL and psychosocial domains can provide further insights regarding the overall impact of treatments. This mini-review discusses the advances and controversies in defining meaningful FI endpoints.
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Affiliation(s)
- S S C Rao
- Division of Gastroenterology/Hepatology, Department of Internal Medicine, Medical College of Georgia, Augusta University, Augusta, GA, USA
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Gräs S, Tolstrup CK, Lose G. Regenerative medicine provides alternative strategies for the treatment of anal incontinence. Int Urogynecol J 2016; 28:341-350. [PMID: 27311602 DOI: 10.1007/s00192-016-3064-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 06/06/2016] [Indexed: 12/17/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Anal incontinence is a common disorder but current treatment modalities are not ideal and the development of new treatments is needed. The aim of this review was to identify the existing knowledge of regenerative medicine strategies in the form of cellular therapies or bioengineering as a treatment for anal incontinence caused by anal sphincter defects. METHODS PubMed was searched for preclinical and clinical studies in English published from January 2005 to January 2016. RESULTS Animal studies have demonstrated that cellular therapy in the form of local injections of culture-expanded skeletal myogenic cells stimulates repair of both acute and 2 - 4-week-old anal sphincter injuries. The results from a small clinical trial with ten patients and a case report support the preclinical findings. Animal studies have also demonstrated that local injections of mesenchymal stem cells stimulate repair of sphincter injuries, and a complex bioengineering strategy for creation and implantation of an intrinsically innervated internal anal sphincter construct has been successfully developed in a series of animal studies. CONCLUSION Cellular therapies with myogenic cells and mesenchymal stem cells and the use of bioengineering technology to create an anal sphincter are new potential strategies to treat anal incontinence caused by anal sphincter defects, but the clinical evidence is extremely limited. The use of culture-expanded autologous skeletal myogenic cells has been most intensively investigated and several clinical trials were ongoing at the time of this report. The cost-effectiveness of such a therapy is an issue and muscle fragmentation is suggested as a simple alternative.
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Affiliation(s)
- Søren Gräs
- Department of Obstetrics and Gynecology, Copenhagen University Hospital Herlev, Herlev Ringvej 75, DK-2730, Herlev, Denmark.
| | - Cæcilie Krogsgaard Tolstrup
- Department of Obstetrics and Gynecology, Copenhagen University Hospital Herlev, Herlev Ringvej 75, DK-2730, Herlev, Denmark
| | - Gunnar Lose
- Department of Obstetrics and Gynecology, Copenhagen University Hospital Herlev, Herlev Ringvej 75, DK-2730, Herlev, Denmark
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Gräs S, Lose G. Does regenerative medicine have a potential role in the treatment of anal incontinence? Colorectal Dis 2016; 18:625-6. [PMID: 27167101 DOI: 10.1111/codi.13379] [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: 08/27/2015] [Accepted: 02/15/2016] [Indexed: 02/08/2023]
Affiliation(s)
- S Gräs
- Department of Obstetrics and Gynecology, Copenhagen University Hospital Herlev, Herlev, Denmark.
| | - G Lose
- Department of Obstetrics and Gynecology, Copenhagen University Hospital Herlev, Herlev, Denmark
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Sokol ER. Management of fecal incontinence - focus on a vaginal insert for bowel control. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2016; 9:85-91. [PMID: 27274318 PMCID: PMC4869843 DOI: 10.2147/mder.s86483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Fecal incontinence, also referred to as accidental bowel leakage, is a debilitating condition that impacts quality of life in a significant number of women. Current treatments for fecal incontinence include behavioral modification, biofeedback, drug therapy, and invasive surgical procedures. However, these treatments have suboptimal efficacy due to patient adherence, variability of presentation across patients, cost, and additional health risks. A vaginal bowel control system (Eclipse™ System) was developed to offer a low-risk, effective, and patient-managed approach to treating accidental bowel leakage. The vaginal bowel control system consists of a vaginal insert and user-controlled, pressure-regulated pump. Once inflated, the balloon of the vaginal insert is directed posteriorly to occlude the rectum, allowing the woman to immediately regain control of bowel function. This article will introduce the design evolution and feasibility studies of the Eclipse System. In addition, this review will discuss the results from a recent clinical trial that demonstrated the safety and efficacy of the vaginal bowel control system in managing fecal incontinence and other symptoms of bowel dysfunction.
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Affiliation(s)
- Eric R Sokol
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
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Electrical Stimulation Followed by Mesenchymal Stem Cells Improves Anal Sphincter Anatomy and Function in a Rat Model at a Time Remote From Injury. Dis Colon Rectum 2016; 59:434-42. [PMID: 27050606 DOI: 10.1097/dcr.0000000000000548] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND We have explored cell-based therapy to aid anal sphincter repair, but a conditioning injury is required to direct stem cells to the site of injury because symptoms usually manifest at a time remote from injury. OBJECTIVE We aimed to investigate the effect of local electrical stimulation followed by mesenchymal stem cell delivery on anal sphincter regeneration at a time remote from injury. DESIGN AND MAIN OUTCOME MEASURES With the use of a rat model, electrical stimulation parameters and cell delivery route were selected based on in vivo cytokine expression and luciferase-labeled cell imaging of the anal sphincter complex. Three weeks after a partial anal sphincter excision, rats were randomly allocated to 4 groups based on different local interventions: no treatment, daily electrical stimulation for 3 days, daily stimulation for 3 days followed by stem cell injection on the third day, and daily electrical stimulation followed by stem cell injection on the first and third days. Histology-assessed anatomy and anal manometry evaluated physiology 4 weeks after intervention. RESULTS The electrical stimulation parameters that significantly upregulated gene expression of homing cytokines also achieved mesenchymal stem cell retention when injected directly in the anal sphincter complex in comparison with intravascular and intraperitoneal injections. Four weeks after intervention, there was significantly more new muscle in the area of injury and significantly improved anal resting pressure in the group that received daily electrical stimulation for 3 days followed by a single injection of 1 million stem cells on the third day at the site of injury. LIMITATION This was a pilot study and therefore was not powered for functional outcome. CONCLUSIONS In this rat injury model with optimized parameters, electrical stimulation with a single local mesenchymal stem cell injection administered 3 weeks after injury significantly improved both new muscle formation in the area of injury and anal sphincter pressures.
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Philpott H, Nandurkar S, Lubel J, Gibson PR. Food, fibre, bile acids and the pelvic floor: An integrated low risk low cost approach to managing irritable bowel syndrome. World J Gastroenterol 2015; 21:11379-11386. [PMID: 26525925 PMCID: PMC4616214 DOI: 10.3748/wjg.v21.i40.11379] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 08/21/2015] [Accepted: 09/30/2015] [Indexed: 02/06/2023] Open
Abstract
Patients presenting with abdominal pain and diarrhea are often labelled as suffering from irritable bowel syndrome, and medications may be used often without success. Advances in the understanding of the causes of the symptoms (including pelvic floor weakness and incontinence, bile salt malabsorption and food intolerance) mean that effective, safe and well tolerated treatments are now available.
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Butt SK, Alam A, Cohen R, Krogh K, Buntzen S, Emmanuel A. Lack of effect of sacral nerve stimulation for incontinence in patients with systemic sclerosis. Colorectal Dis 2015; 17:903-7. [PMID: 25850948 DOI: 10.1111/codi.12969] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 12/31/2014] [Indexed: 12/13/2022]
Abstract
AIM Systemic sclerosis (SSc) is a multisystem disorder of unknown aetiology leading to the deposition of excessive connective tissue in the skin, blood vessels and internal organs. Gastrointestinal involvement occurs in 90% of cases and the prevalence of faecal incontinence (FI) is 38%. This study comprises the largest case series assessing the efficacy of sacral nerve stimulation (SNS) treatment for incontinence in this patient group. METHOD A retrospective analysis on prospectively collected data was performed on all SSc patients from our two centres who had undergone SNS for FI. RESULTS Ten female patients of mean age of 54 (37-72) years had temporary SNS performed. The mean duration of FI was 13 (2-25) years. All had passive FI. Each patient had preprocedure anorectal physiology and endoanal ultrasound examinations documenting internal sphincter atrophy/fragmentation or reduced anal resting pressure. Overall there was no statistically significant difference (P = 0.57) in the total Wexner incontinence scores before (mean 15.1 ± 2.6 SD) and during temporary SNS procedures (mean 13.1 ± 3.6 SD). Two patients with a significant improvement went on to have permanent SNS with only one achieving a favourable outcome at 1 year. CONCLUSION This study showed that SNS failed to reduce episodes of leakage in nine out of 10 patients with systemic sclerosis affected with incontinence.
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Affiliation(s)
- S K Butt
- Neurogastroenterology Unit, Royal Free and University College Hospital NHS Trust, London, UK
| | - A Alam
- Neurogastroenterology Unit, Royal Free and University College Hospital NHS Trust, London, UK
| | - R Cohen
- Neurogastroenterology Unit, Royal Free and University College Hospital NHS Trust, London, UK
| | - K Krogh
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - S Buntzen
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - A Emmanuel
- Neurogastroenterology Unit, Royal Free and University College Hospital NHS Trust, London, UK
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