Fecal incontinence

Clinical guidelines “Chronic diarrhea in adults”

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Chronic constipation in adults: Contemporary perspectives and clinical challenges. 1: Epidemiology, diagnosis, clinical associations, pathophysiology and investigation

BACKGROUND

Chronic constipation is a prevalent disorder that affects patients' quality of life and consumes resources in healthcare systems worldwide. In clinical practice, it is still considered a challenge as clinicians frequently are unsure as to which treatments to use and when. Over a decade ago, a Neurogastroenterology & Motility journal supplement devoted to the investigation and management of constipation was published (2009; 21 (Suppl.2)). This included seven articles, disseminating all themes covered during a preceding 2-day meeting held in London, entitled "Current perspectives in chronic constipation: a scientific and clinical symposium." In October 2018, the 3rd London Masterclass, entitled "Contemporary management of constipation" was held, again over 2 days. All faculty members were invited to author two new review articles, which represent a collective synthesis of talks presented and discussions held during this meeting.

PURPOSE

This article represents the first of these reviews, addressing epidemiology, diagnosis, clinical associations, pathophysiology, and investigation. Clearly, not all aspects of the condition can be covered in adequate detail; hence, there is a focus on particular "hot topics" and themes that are of contemporary interest. The second review addresses management of chronic constipation, covering behavioral, conservative, medical, and surgical therapies.

Long-term outcome of sacral nerve stimulation for faecal incontinence

AIM

Sacral nerve stimulation (SNS) is a minimally invasive treatment for faecal incontinence (FI). We report our experience of patients who have undergone SNS for FI with a minimum of 5 years' follow-up. This is a single centre prospective observational study with the aim to assess the long-term function of SNS.

METHOD

All patients implanted with SNS were identified from our prospective database. The date of implantation, first and last clinic follow-up, surgical complications and St Mark's incontinence scores were abstracted and analysed.

RESULTS

From 1996 to 2014, 381 patients were considered for SNS. Of these, 256 patients met the study inclusion criteria. Median age at implantation was 52 years (range 18-81). The ratio of women to men was 205:51. Indications were urge FI (25%), passive FI (17.9%) and mixed FI (57%). The median of the incontinence score at baseline was 19/24 and this improved to 7/24 at the 6-month follow-up. Of the total cohort, 235 patients received a medium-term follow-up (median 110 months, range 12-270) with a median continence score of 10/24 which was also confirmed at the telephone long-term follow-up on 185 patients (132 months, range 60-276).

CONCLUSION

This study demonstrates that SNS is an effective treatment in the long term. SNS results in an improvement of validated scores for approximately 60% of patients; however, there is a significant reduction of efficacy over time due to underlying causes.

Coexistent faecal incontinence and constipation: A cross-sectional study of 4027 adults undergoing specialist assessment

BACKGROUND

In contrast to paediatric and geriatric populations, faecal incontinence and constipation in adults are generally considered separate entities. This may be incorrect.

METHODS

Cross-sectional study of consecutive patients (18-80 years) referred to a tertiary unit (2004-2016) for investigation of refractory faecal incontinence and/or constipation and meeting Rome IV core criteria (applied post-hoc) for self-reported symptoms. We sought to determine how frequently both diagnoses coexisted, how frequently coexistent diagnoses were recognised by the referring clinician and to evaluate differences in clinical characteristics between patients with single or both diagnoses.

FINDINGS

Study sample consisted of 4,027 patients (3,370 females [83·7%]). According to Rome IV criteria, 807 (20·0%) patients self-reported faecal incontinence in isolation, 1,569 (39·0%) patients had functional constipation in isolation, and 1,651 (41·0%) met criteria for both diagnoses (coexistent symptoms). In contrast, only 331 (8·2%) patients were referred for coexistent symptoms. Of the 1,651 patients with self-reported coexistent symptoms, only 225 (13·6%) were recognised by the referrer i.e. 86·4% were missed. Coexistent symptoms were most often missed in patients referred for faecal incontinence in isolation. In this group of 1,640 patients, 765 (46·7%) had concomitant symptoms of functional constipation. Opioid usage, comorbidities, childhood bowel problems, mixed incontinence symptoms, prolapse symptoms and structural abnormalities on defaecography were associated with reclassification.

INTERPRETATION

Over 40% of adults referred for anorectal physiological investigation had coexistent diagnoses of faecal incontinence and functional constipation, based on validated criteria. This overlap is overlooked by referrers, poorly documented in current literature, and may impact management.

Clinical Evaluation of a Patient With Symptoms of Colonic or Anorectal Motility Disorders

Constipation, irritable bowel syndrome, fecal incontinence, abdominal pain, and anorectal pain are problems that affect 40% of the population. They commonly present with overlapping symptoms indicating that their pathophysiology affects multiple segments of the gut as well as brain and gut interactions. Clinically, although some conditions are readily recognized, dyssynergic defecation, fecal incontinence, and anorectal pain are often missed or misdiagnosed. Consequently, the assessment of lower gastrointestinal symptoms in patients with suspected colonic or anorectal motility disorder(s) remains challenging for most clinicians. A detailed history, use of the Bristol stool form scale, prospective stool diaries, ideally through a phone App, digital rectal examination, and judicious use of complementary diagnostic tests are essential. Additionally, it is important to evaluate the impact of these problems on quality of life and psychosocial issues, because they are intricately linked with these disorders. The Rome IV diagnostic questionnaire for functional gastrointestinal disorders can provide additional information often missed during history taking. Here, we discuss a systematic approach for the clinical evaluation of patients with suspected lower gastrointestinal problems, grouped under 4 common diagnostic categories. We describe how to take a detailed history, perform meticulous digital rectal examination, and use validated tools to supplement clinical evaluation, including assessments of quality of life and scoring systems for disease severity and digital Apps. These tools could facilitate a comprehensive plan for clinical management including diagnostic tests, and translate the patients' complaints into definable, diagnostic categories.

Guidelines for the investigation of chronic diarrhoea in adults: British Society of Gastroenterology, 3rd edition

Chronic diarrhoea is a common problem, hence clear guidance on investigations is required. This is an updated guideline from 2003 for the investigations of chronic diarrhoea commissioned by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG). This document has undergone significant revision in content through input by 13 members of the Guideline Development Group (GDG) representing various institutions. The GRADE system was used to appraise the quality of evidence and grading of recommendations.

Fecal Incontinence in Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis

BACKGROUND

Understanding of the prevalence, pathophysiology, and management of fecal incontinence (FI) in inflammatory bowel disease (IBD) patients without an ileal pouch anal anastomosis (IPAA) is suboptimal. We conducted a systematic review and meta-analysis on the prevalence, pathophysiology, and management of primary FI in IBD patients without IPAA.

METHODS

We searched MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews (1966 through March 2017) for studies on the prevalence, physiology, or management of FI in IBD patients without IPAA. A random effects model was used to calculate pooled prevalence rates and odds ratio (OR) with 95% confidence interval (CI). Heterogeneity was assessed with I2 statistics, Cochran Q statistic, and sensitivity analyses.

RESULTS

Seventeen studies were included. Six studies evaluated the prevalence of FI in 4671 IBD patients. There was significant heterogeneity among the studies, but the pooled prevalence of FI among case-control studies was homogeneous at 24% (95% CI 18%-30%, I2 = 50.6%, P = 0.16). FI was more common among IBD patients than non-IBD controls (OR = 7.73; 95% CI 6.26 to 9.84). Therapeutic options were poorly evaluated in uncontrolled studies. Surgery was effective in 70% of patients (7/10), sacral nerve stimulation was effective in 100% of patients (5/5), and 41.6% of patients (5/12) reported subjective improvement in FI with percutaneous tibial nerve stimulation.

CONCLUSIONS

FI is prevalent in IBD patients without IPAA, and more common than non-IBD controls. Additional controlled studies are warranted to further identify effective therapeutic interventions for FI in IBD. 10.1093/ibd/izx109_video1izx109_Video_15760611117001.

Short-term outcome of percutaneous posterior tibial nerve stimulation (PTNS) for the treatment of faecal incontinence

BACKGROUND

The aim of the present study was to establish the efficacy of percutaneous posterior tibial nerve stimulation (PTNS) in treating flatal, urge and passive faecal incontinence (FI).

METHODS

A prospective study with 55 patients with FI was carried out. Clinical anamnesis, physical examination, a reverse visual analogue scale (VAS) score, Wexner score and the American Society of Colon and Rectal Surgeons quality of life score were recorded at baseline and 6 months, along with an incontinence diary. Subjects underwent one weekly session for 12 consecutive weeks and then continued with six additional fortnightly sessions. An intention-to-treat analysis was performed.

RESULTS

Fifty-five patients (44 females; mean age 58.62 ± 10.74 years) with FI were treated with PTNS. The origins of the incontinence were obstetric (52.7 %) and perineal surgery (34.5 %). Eight patients did not continue with the second stage of treatment. The median Wexner baseline value was 9.98. After 6 months, it had decreased to 4.55 (p < 0.001). The visual analogue scale (VAS) increased from 4.94 to 6.80 (p < 0.001). There was a significant improvement in lifestyle, coping/behaviour, depression/self-perception and embarrassment scores. With respect to different types of FI, there was an improvement in the Wexner score both in patients with true passive FI and in those with urge or mixed FI.

CONCLUSIONS

PTNS is an effective treatment for FI. Patients with passive or urge FI can benefit from this therapy, with improvement of the Wexner score and quality of life variables.

Advances in the Surgical Treatment of Fecal Incontinence

Although surgery for fecal incontinence has been shown to be effective, it is still very challenging and sometimes frustrating. Overlapping sphincteroplasty, by far the most common procedure, is effective in patients with sphincter defects; however, recent data suggest that success rates tend to deteriorate over time. A thorough preoperative evaluation incorporates numerous factors, including patient characteristics, severity of incontinence, type and size of the sphincter defect as assessed by physical examination, anal ultrasound, and anorectal physiology studies including anal manometry, electromyography, and pudendal nerve terminal motor latency assessment. The use of these evaluation methods has allowed better patient assignment for a variety of new alternative treatment options. Innovations in the surgical treatment of fecal incontinence range from simple, office-based sphincter augmentation techniques to surgical implantation of mechanical devices. This article reviews 5 alternative surgical treatment options for fecal incontinence: injection of carbon-coated beads in the submucosa of the anal canal, radiofrequency energy delivery, stimulated graciloplasty, artificial bowel sphincter, and sacral nerve stimulation.

Outpatient management of inflammatory bowel disease

Inflammatory bowel disease is a conglomeration of disorders of unclear etiology and pathogenesis. Confirming the diagnosis of active disease may be difficult but is critical to judicious therapy. Sulfasalazine (Azulfidine) and its newer derivatives mesalamine (Asacol, Rowasa) and olsalazine sodium (Dipentum) are used for treatment of mild disease and maintenance. Corticosteroid therapy controls moderate disease in most patients, but withdrawal may be difficult. Immunosuppression or surgery may be necessary in severe or refractory cases. The risk of cancer as a complication of inflammatory bowel disease is often exaggerated but cannot be ignored.

Prevalence, trends, and risk factors for fecal incontinence in United States adults, 2005-2010

BACKGROUND & AIMS

We investigated the prevalence of and trends and risk factors for fecal incontinence (FI) in the United States among non-institutionalized adults from 2005 to 2010.

METHODS

We analyzed data from 14,759 participants in the U.S. National Health and Nutrition Examination Survey (49% women, 20 years or older) from 2005 to 2010 (the FI Severity Index was added in 2005-2006). FI was defined as accidental leakage of solid or liquid stool or mucus at least once in preceding month. Sampling weights were used to obtain estimates for the national population. Logistic regression was used to identify risk factors for FI.

RESULTS

The prevalence of FI among non-institutionalized U.S. adults was 8.39% (95% confidence interval, 7.76-9.05). It was stable throughout the study period: 8.26% in 2005-2006, 8.48% in 2007-2008, and 8.41% in 2009-2010. FI resulted in release of liquid stool in most cases (6.16%). Prevalence increased with age from 2.91% among 20- to 29-year-old participants to 16.16% (14.15%-18.39%) among participants 70 years and older. Independent risk factors for FI included older age, diabetes mellitus, urinary incontinence, frequent and loose stools, and multiple chronic illnesses. FI was more common among women only when they had urinary incontinence.

CONCLUSIONS

FI is a common problem among non-institutionalized U.S. adults. Its prevalence remained stable from 2005-2010. Diabetes mellitus and chronic diarrhea are modifiable risk factors. Future studies on risk factors for FI should assess for presence of urinary incontinence.

Anorectal incontinence: a challenge in diagnostic and therapeutic approach

Anorectal incontinence is a symptom of a complex multifactorial disorder involving the pelvic floor and anorectum, which is a severe disability and a major social problem. Various causes may affect the anatomical and functional integrity of the pelvic floor and anorectum, leading to the anorectal continence disorder and incontinence. The most common cause of anorectal incontinence is injury of the sphincter muscles following delivery or anorectal surgeries. Although the exact incidence of anorectal incontinence is unknown, various studies suggest that it affects ~2.2-8.3% of adults, with a significant prevalence in the elderly (>50%). The successful treatment of anorectal incontinence depends on the accurate diagnosis of its cause. This can be achieved by a thorough assessment of patients. The management of incontinent patients involves conservative therapeutic procedures, surgical techniques, and minimally invasive approaches.

Urogenital consequences in ageing women

Various anatomical, physiological, genetic, lifestyle and reproductive factors interact throughout a woman's life span and contribute to pelvic floor disorders. Ageing affects pelvic floor anatomy and function, which can result in a variety of disorders, such as pelvic organ prolapse, lower urinary tract symptoms, dysfunctional bowel and bladder evacuation, and sexual dysfunction. The exact mechanisms and pathophysiological processes by which ageing affects pelvic floor and lower urinary and gastrointestinal tract anatomy and function are not always clear. In most cases, it is difficult to ascertain the exact role of ageing per se as an aetiological, predisposing or contributing factor. Other conditions associated with ageing that may co-exist, such as changes in mental status, can result in different types of pelvic floor dysfunction (e.g. functional incontinence). Pelvic organ dysfunction may be associated with significant morbidity and affect quality of life. These groups of patients often pose difficult diagnostic and therapeutic dilemmas owing to complex medical conditions and concurrent morbidities. In this chapter, we summarise the current evidence on the management of pelvic floor disorders, with emphasis on elderly women and the associations between the ageing process and these disorders. Clinicians with an understanding of the affect of ageing on the pelvic floor and lower urinary and gastrointestinal tract anatomy and function, and the complex interplay of other comorbidities, will be able to investigate, diagnose and treat appropriately there women. A holistic approach may result in substantial improvements in their quality of life.

Long-term durability of sacral nerve stimulation therapy for chronic fecal incontinence

BACKGROUND

Limited data have been published regarding the long-term results of sacral nerve stimulation, or sacral neuromodulation, for severe fecal incontinence.

OBJECTIVES

The aim was to assess the outcome of sacral nerve stimulation with the use of precise tools and data collection, focusing on the long-term durability of the therapy. Five-year data were analyzed.

DESIGN

Patients entered in a multicenter, prospective study for fecal incontinence were followed at 3, 6, and 12 months and annually after device implantation.

PATIENTS

Patients with chronic fecal incontinence in whom conservative treatments had failed or who were not candidates for more conservative treatments were selected.

INTERVENTIONS

Patients with ≥ 50% improvement over baseline in fecal incontinence episodes per week during a 14-day test stimulation period received sacral nerve stimulation therapy.

MAIN OUTCOME MEASURES

Patients were assessed with a 14-day bowel diary and Fecal Incontinence Quality of Life and Fecal Incontinence Severity Index questionnaires. Therapeutic success was defined as ≥ 50% improvement over baseline in fecal incontinence episodes per week. All adverse events were collected.

RESULTS

A total of 120 patients (110 women; mean age, 60.5 years) underwent implantation. Seventy-six of these patients (63%) were followed a minimum of 5 years (maximum, longer than 8 years) and are the basis for this report. Fecal incontinence episodes per week decreased from a mean of 9.1 at baseline to 1.7 at 5 years, with 89% (n = 64/72) having ≥ 50% improvement (p < 0.0001) and 36% (n = 26/72) having complete continence. Fecal Incontinence Quality of Life scores also significantly improved for all 4 scales between baseline and 5 years (n = 70; p < 0.0001). Twenty-seven of the 76 (35.5%) patients required a device revision, replacement, or explant.

CONCLUSIONS

The therapeutic effect and improved quality of life for fecal incontinence is maintained 5 years after sacral nerve stimulation implantation and beyond. Device revision, replacement, or explant rate was acceptable, but future efforts should be aimed at improvement.

[Direct sphincter repair: techniques, indications and results]

L'incontinence anale est un handicap physique, psychique et social majeur qui a de nombreuses causes différentes. Les méthodes actuellement disponibles pour améliorer les symptômes de cette incontinence sont les méthodes médicales et de rééducation d'une part et les méthodes chirurgicales d'autre part. Quatre techniques chirurgicales répondent à ces objectifs pour la plupart des malades: la sphinctérorraphie, la neuromodulation des racines sacrées, et les deux techniques de substitution que sont le sphincter artificiel et la graciloplastie dynamisée. La réparation sphinctérienne directe est la technique la plus utilisée dans le traitement chirurgical de l'incontinence anale (IA) par lésion sphinctérienne. Cette technique est envisageable chez les malades ayant une incontinence fécale en rapport avec des lésions limitées du sphincter anal externe. La technique chirurgicale est simple (myorraphie par suture directe ou en paletot) et bien codifiée. Les résultats fonctionnels sont imparfaits et se dégradent avec la durée du suivi. Une continence parfaite après réparation sphinctérienne est rarement acquise de façon durable: le malade candidat à cette approche thérapeutique doit en être averti.

Factors associated with symptom severity in women presenting with fecal incontinence

BACKGROUND

Fecal incontinence (FI) affects 2-12% of the US population. Identification of factors associated with worsening symptoms has important implications for prevention and treatment.

OBJECTIVE

The aim of our study is to assess factors associated with symptom severity in women presenting with FI.

DATA SOURCES

This was a prospective survey study.

STUDY SELECTION

Patients presenting to the Michigan Bowel Control Program Clinic for FI were prospectively enrolled between May 2005 and May 2009.

MAIN OUTCOME MEASURES

Factors associated with fecal incontinence severity.

RESULTS

Data on 231 women was analyzed with a mean age of 59.2 years (SD = 14.2) and mean BMI of 30.0 (SD = 8.6); 92% were white. Mean FISI score was 32.4 (SD = 15.3). Two-thirds of patients had a type 1-4 stool on the Bristol stool scale. Forty-one percent of subjects complained of urinary incontinence, 56.2% had an episiotomy, 29% had an operative delivery, and 15.1% reported a severe laceration with childbirth. The majority of patients (86.1%) reported FI for greater than 1 year, and 65.4% had previously sought care for FI. Bivariate analysis revealed that diabetes, IBS, urinary incontinence, history of operative delivery or severe laceration, fecal urgency, longer history of symptoms, previous health care for FI, and belief in treatment were positively associated with worse FISI score. In multiple linear regression analysis, increased FI symptom severity was shown to be associated with fecal urgency (0.0004), history of episiotomy (0.04), urinary incontinence (0.02), and diabetes mellitus (0.004).

LIMITATIONS

This was a cross-sectional survey study performed at a Tertiary care center.

CONCLUSION

Patients with a history of episiotomy, diabetes, urinary incontinence, and fecal urgency have increased FI symptom severity. Proactive screening of patients with these medical histories is needed.

A systematic review of psychometric evidence and expert opinion regarding the assessment of faecal incontinence in older community-dwelling adults

Objectives  This review had two objectives: (i) to determine what is required in an assessment of faecal incontinence issues for older community-dwelling adults; and (ii) to determine the psychometric tools most effective for assessment of faecal incontinence in older community-dwelling adults. Inclusion criteria  For the review of psychometric tools, studies were included if they were concerned with people living in the community, included a significant proportion of the sample aged 65 years or over, and either examined psychometric properties of assessment tools or assessed sensitivity of assessment tools to non-surgical interventions available in the community setting. For the review of expert opinion, the search was limited to expert opinion provided by an expert in faecal incontinence that related to community-based assessment. Only articles published in English were eligible for inclusion and no limits were placed on publication dates. Search strategy  An initial search of Medline and CINAHL databases identified terminology frequently used in the literature with regard to assessment of faecal incontinence. An extensive search was then undertaken using all identified key words and index terms. The third step involved a search of reference lists and bibliographies of all relevant articles. Methodological quality  All identified studies that met the inclusion criteria were assessed for methodological validity in the case of studies considered for inclusion in the psychometric review. Validity of expert text was also assessed prior to it being included in the review. Results  The final search strategy identified approximately 7000 references. Full-text versions of 144 references were critically appraised for inclusion in the review. Of these, 25 sources were included in the review of expert opinion and 16 in the review of psychometric properties. In the review of expert opinion, 254 conclusions were extracted for synthesis. The 31 thematic categories were organised under five major themes: History-taking, bowel assessment, psychosocial aspects, physical examination and specialist referral. From the sources that survived critical appraisal, 52 conclusions relating to psychometric properties of assessment tools were derived. There was limited, if any, analysis of psychometric properties for the majority of assessment tools. The Wexner and Vaizey symptom severity scales demonstrated acceptable test-retest reliability and convergent validity. The Fecal Incontinence Quality of Life Scale (FIQLS) demonstrated reasonable reliability and good convergent and criterion-related validity. There was, however, some evidence questioning its discriminant validity. Conclusions  This systematic review represents an important first stage in developing guidelines for assessment of faecal incontinence in community-dwelling older people. Assessment should be comprehensive in nature. Gaps in expert opinion are evident regarding issues such as assessment of cognitive decline and specialist referral. Continence advisors need to be appropriately trained in using and interpreting results from assessment tools and conducting physical examinations. Although studies in the review of psychometric properties suffer from limitations such as inadequate sample sizes, the Vaizey and Wexner scales would appear to be the tools of choice. The FIQLS is clearly the tool of choice at this stage for measuring faecal incontinence quality of life. Further validation of tests used in faecal incontinence assessments is required.

Normative values in anorectal manometry using microtip technology: a cohort study in 172 subjects

PURPOSE

The aims of this study were to obtain normative values in resting/squeeze pressure and surface electromyography (s-EMG) in anorectal manometry using microtip technology and to determine the relationship between objective measurable values, gender and age in a cohort with no anorectal disorders.

METHODS

One hundred seventy-two white central European subjects (106 males/66 females) were recruited prior to left colonic or upper rectal surgery and studied by anorectal rapid pull-through manometry with a microtip transducer system and endoanal s-EMG using a bipolar plug electrode. s-EMG patterns were determined as plateau, peak and decrease by a blinded co-investigator. Objective measurable sphincter pressures and s-EMG values were correlated with gender, age and s-EMG patterns.

RESULTS

Squeeze pressure, voluntary pressure as well as s-EMG amplitude and its area under the curve were significantly lower in women compared to men (p < 0.001 each), whereas resting pressure showed no gender differences. s-EMG patterns were strongly influenced by gender. Male patients showed significantly more plateau pattern whereas peak pattern was significantly more often in women. In both genders, the peak pattern was associated with significant higher squeeze pressures. In all measurements, we found considerable inter-individual variations being higher in elder patients. There was no manometric parameter correlating with age.

CONCLUSIONS

Gender is the strongest factor influencing objective measurable manometric data for healthy men and women. There are significant gender differences concerning squeeze patterns. All manometric values should be interpreted in the context of gender and of methodology used. Large prospective cohort studies matched for gender are necessary to clarify the effect of ageing on anal sphincter strength.

Sacral nerve stimulation in the elderly

AIM

Increasing life expectancy will increase the number of elderly patients with faecal incontinence. The study aimed to assess the safety and efficacy of sacral nerve stimulation (SNS) in patients over the age of 65 years.

METHOD

Patients aged over 65 years, who underwent temporary SNS from 1996 for faecal incontinence unresponsive to conservative treatment, were followed prospectively.

RESULTS

Between January 1996 and December 2009, 30 patients [mean age 69.3 years (SD, 3.4)] underwent temporary SNS. Twenty-three (77%) had a >50% improvement in the St Mark's Continence Score and progressed to permanent SNS implantation. Their mean (±SD) score increased from 19 (3.2) at baseline to 8 (3.4) during temporary SNS and to 9 (3.4) 3 months after permanent SNS and 10 (3.7) at the latest median follow up (IQR) of 44 (20-150) months. The corresponding values at the same intervals for urgency [mean (±SD) min] were 1 (1.4), 8 (5.2), 8 (5) and 8 (5.4) and for incontinence episodes per 2 weeks [median (±IQR)] were 10 (7-14), 1 (0-5), 2 (0-5) and 0 (0-6).

CONCLUSION

SNS is an effective treatment for faecal incontinence in patients over 65 years.

Accuracy of the digital anal examination in women with fecal incontinence

INTRODUCTION AND HYPOTHESIS

This study aims to determine the accuracy of digital rectal examination (DRE) to detect anal sphincter defects when compared to endoanal ultrasound (US) in women with fecal incontinence (FI).

METHODS

Seventy-four patients identified by retrospective chart review who presented with complaints of bothersome FI who underwent endoanal US are the subjects of this analysis. Sensitivity, specificity, and positive and negative likelihood ratios were calculated for the ability of the DRE to detect anal sphincter defects.

RESULTS

Anal sphincter defect was suspected on DRE in 75%. At endoanal US, external sphincter defects were noted in all three segments in 41% (complete defect) while partial defects were noted in 30%. DRE demonstrated a sensitivity of 82%, specificity of 32%, +likelihood ratio 1.2 (95% confidence interval (CI), 0.95-1.16) and -likelihood ratio of 0.6 (95% CI, 0.2-1.24) for detecting a complete EAS defect on endoanal US.

CONCLUSION

DRE has poor specificity for detecting anal sphincter defects seen on endoanal US.

Posterior tibial nerve stimulation and faecal incontinence: a review

PURPOSE

Faecal incontinence is a common and important multifactorial disorder with a range of treatment options. Over the last two decades, neuromodulation via sacral nerve stimulators has been shown to be effective for both faecal and urinary incontinence, although associated with complications. Peripheral neuromodulation, via the posterior tibial nerve, is widely used in urinary incontinence; however, its use in faecal incontinence, whilst evolving is limited to eight small heterogeneous studies.

REVIEW

These eight studies are discussed in the context of the methodology and underlying neurophysiology of peripheral neuromodulation, as are thus far unanswered questions. The eight studies include a total of 129 patients with faecal incontinence (of variable aetiology), all of whom had failed conservative management. One study was prospective and controlled, six were uncontrolled and one was retrospective and uncontrolled. Five different neuromodulatory protocols were used over six different study periods. Outcome measures varied, but short term primary endpoint success ranged from 30.0% to 83.3%. The limitations to this early evidence, whilst encouraging, are significant, and it remains to be seen whether this novel treatment modality represents the minimally invasive, well-tolerated, cost-effective and flexible panacea hoped for this common and debilitating disease. Three upcoming multicentre placebo-controlled trials will better be able to delineate its role.

Approach to fecal incontinence and constipation in older hospitalized patients

Although constipation and fecal incontinence are commonly encountered in older hospitalized patients, there is a paucity of clinical studies in this field. In this article we discuss the approach to and management of patients with these problems based on evidence and studies performed on patients in the ambulatory care setting, nursing home setting, and our experience. Our recommendations are applicable to older hospitalized patients. Successful management of these patients depends on identifying and treating underlying cause(s), such as infection, dietary factors, medication, or immobility-induced incontinence, constipation, or fecal impaction. For a hospitalized patient, a digital rectal examination should be performed to rule out fecal impaction and overflow incontinence. If there is no impaction but a weak anal sphincter, stool softeners or laxatives should be discontinued, as they cause diarrhea/fecal incontinence. In a patient with diarrhea/incontinence and suspected infection, management includes checking stool for Clostridium difficile toxin, E0157, ova and parasites, and culture. If the patient is on enteral nutrition, osmotic diarrhea-induced incontinence should be considered. Nursing care includes use of absorbent pads, special undergarments, anal hygiene, and skin care. Medications such as loperamide or diphenoxylate/atropine are useful for diarrhea with incontinence. Laxatives (eg, polyethylene glycol, lactulose), secretagogues (eg, lubiprostone), enemas, suppositories, and timed toileting assistance may be effective for constipation. Despite appropriate management, older hospitalized patients may remain incontinent because of dementia, immobility, or comorbid issues. Treatment should be tailored to the underlying mechanism(s) and needs of each patient.

Pathophysiology of anal incontinence, constipation, and defecatory dysfunction

Anorectal disorders cause significant discomfort and embarrassment in women. The onset typically follows childbirth and symptoms increase with age. This article discusses anal incontinence, defecatory dysfunction, rectal prolapse, and constipation.

Fecal incontinence in an inpatient population: a not uncommon finding

The prevalence of fecal incontinence (FI) in hospitalized patients was determined, as well as the frequency with which physicians query about FI. Using a standardized questionnaire, subjects admitted to general medicine services at three university hospitals were questioned about FI. Investigators also reviewed the subjects' charts to determine if presence or absence of FI was documented. One hundred ninety-nine patients were enrolled, and 46% (92/199) reported ongoing FI. Advanced age, looser stools, symptoms of fecal urgency, urinary incontinence, and history of forceps delivery were found to be potential predictors of FI. Only 6% (6/92) with FI had documentation of FI in the medical chart and only 3% (6/199) of the entire sample were queried about FI. Fecal incontinence is an extremely common condition in hospitalized patients. Physician history-taking is severely deficient in this area. Methods to improve FI detection in the hospitalized patient population need to be developed.

Fecal incontinence in the elderly

Fecal incontinence affects up to 20% of community-dwelling adults and more than 50% of nursing home residents, and is one of the major risk factors for elderly persons in the nursing home. Institutionalization itself is a risk factor (eg, immobility due to physical restraints). Management should focus on identifying and treating underlying causes, such as diet- or medication induced diarrhea, constipation, and fecal impaction. Use of absorbent pads and special undergarments is useful. Anorectal physiologic testing of nursing home residents has revealed an association between constipation, stool retention, and fecal incontinence. Impaired sphincter function (risk factor for fecal incontinence), decreased rectal sensation, and sphincter dyssynergia (risk factor for constipation and impaction) are found in a high proportion of incontinent nursing home residents. Biofeedback and sacral nerve stimulation may be useful in refractory patients and should be considered before colostomy in community-dwelling adults. Despite appropriate management, nursing home residents may remain incontinent because of dementia and health or restraint related immobility.

Surgery and sacral nerve stimulation for constipation and fecal incontinence

Fecal continence is a complex bodily function, which requires the interplay of sensation, rectal capacity, and anal neuromuscular function. Fecal incontinence affects approximately 2% of the population and has a prevalence of 15% in elderly patients. Constipation is one of the most common gastrointestinal disorders. The variety of symptoms and risk factors suggest a multifactorial origin. Before any invasive intervention, the surgeon should have a thorough understanding of the etiology of these conditions. Appropriate medical management can improve symptoms in the majority of patients. Surgery is indicated when all medical possibilities are exhausted. This review discusses the most used surgical procedures emphasizing the latest experiences. Sacral nerve stimulation (SNS) is a promising option for patients with fecal incontinence and constipation. The procedure affords patients improved continence and quality of life. The mechanism of action is still poorly understood. This treatment has been used before in other more invasive surgical procedures or even after their failure to improve patients' symptoms and avoid a definitive stoma. Before any invasive intervention, the surgeon should have a thorough understanding of the etiology of these conditions. Appropriate medical management can improve symptoms in the majority of patients. Surgery is indicated when all medical possibilities are exhausted. This review discusses the most used surgical procedures emphasizing the latest experiences. Sacral nerve stimulation (SNS) is a promising option for patients with fecal incontinence and constipation. The procedure affords patients improved continence and quality of life. The mechanism of action is still poorly understood. This treatment has been used before in other more invasive surgical procedures or even after their failure to improve patients' symptoms and avoid a definitive stoma.

A cost-effectiveness analysis of delayed sphincteroplasty for anal sphincter injury

OBJECTIVE

Anal-sphincter injury may result in faecal incontinence. Sphincteroplasty is usually performed as a primary (immediate) procedure. Delayed sphincteroplasty (DS) can be performed if there is significant trauma or soiling, if the primary procedure has failed, and if the injury was not recognized initially. This study aimed to determine the cost to patient and health service in the event a DS is performed.

METHOD

Patients with anal-sphincter-injury who underwent primary sphincteroplasty (PS)/DS were identified from the published literature (primary, n = 103; delayed, n = 777) using Medline, Embase, Ovid and Cochrane databases for studies published between 1976 and 2006. Studies included described at least one of the measured outcomes--probability of functional success/failure and quality of life (QOL). An economic model was constructed and decision analysis performed using a decision tree based on a Markov process. Main outcomes were quality-adjusted-life-years (QALYs) gained from each strategy, costs incurred and incremental cost-effectiveness ratio (ICER) over a 10- and 15-year time horizon.

RESULTS

Over 10 years, primary sphincteroplasty (PS) produced a gain of 5.72 QALYs for an estimated 2750 pounds, giving an ICER of 487 pounds per QALY. DS produced a gain of 3.73 QALYs for a cost of 2667 pounds, giving an ICER of 719 pounds per QALY. Both procedures fell below the 10,000 pounds per QALY willingness-to-pay threshold, but PS produced the highest QALYs. Both procedures performed poorly beyond the 10-year mark.

CONCLUSION

If DS has to be performed, the resultant cost is greater with concurrently lower QALYs gained. Successful PS substantially improves QOL and reduces overall cost-of-treatment.

Urinary and fecal incontinence in nursing home residents

Urinary and fecal incontinence are comorbid conditions affecting over 50% of nursing home residents. Management should focus on identifying and treating underlying causes. Despite appropriate management, residents may remain incontinent because of dementia and health- or restraint-related immobility. This article reviews the results of studies that have documented how prompted voiding programs can significantly reduce urinary and fecal incontinence, particularly if the intervention includes dietary and exercise components. Documentation of noninvasive and efficacious interventions by randomized, controlled trials and the labor costs of implementing these measures can lead to changes in how nursing home care is provided and funded.

Sacral nerve stimulation is more effective than optimal medical therapy for severe fecal incontinence: a randomized, controlled study

PURPOSE

This randomized study was designed to compare the effect of sacral neuromodulation with optimal medical therapy in patients with severe fecal incontinence.

METHODS

Patients (aged 39-86 years) with severe fecal incontinence were randomized to have sacral nerve stimulation (SNS group; n = 60) or best supportive therapy (control; n = 60), which consisted of pelvic floor exercises, bulking agent, and dietary manipulation. Full assessment included endoanal ultrasound, anorectal physiology, two-week bowel diary, and fecal incontinence quality of life index. The follow-up duration was 12 months.

RESULTS

The sacral nerve stimulation group was similar to the control group with regard to gender (F:M = 11:1 vs. 14:1) and age (mean, 63.9 vs. 63 years). The incidence of a defect of < or = 120 degrees of the external anal sphincter and pudendal neuropathy was similar between the groups. Trial screening improved incontinent episodes by more than 50 percent in 54 patients (90 percent). Full-stage sacral nerve stimulation was performed in 53 of these 54 "successful" patients. There were no septic complications. With sacral nerve stimulation, mean incontinent episodes per week decreased from 9.5 to 3.1 (P < 0.0001) and mean incontinent days per week from 3.3 to 1 (P < 0.0001). Perfect continence was accomplished in 25 patients (47.2 percent). In the sacral nerve stimulation group, there was a significant (P < 0.0001) improvement in fecal incontinence quality of life index in all four domains. By contrast, there was no significant improvement in fecal continence and the fecal incontinence quality of life scores in the control group.

CONCLUSIONS

Sacral neuromodulation significantly improved the outcome in patients with severe fecal incontinence compared with the control group undergoing optimal medical therapy.

Sacral nerve stimulation for faecal incontinence

BACKGROUND

Faecal incontinence resulting from obstetric injury is a socially disabling condition with a significant impact on quality of life. Sacral nerve stimulation (SNS) is a relatively new treatment modality, which offers patients a potential for improved continence.

METHODS

We reviewed our initial experience of SNS in 14 patients (mean age 54 years, range 30-72) with faecal incontinence from January 2006 to June 2007. Background demographics, past medical and obstetric history, anal manometry, endoanal ultrasound and pudendal nerve studies were recorded on all patients. All patients who had permanent SNS implants inserted had pre and post operative questionnaires consisting of the Wexner Continence Score and the Rockwood and SF-36 Quality of Life Indices.

RESULTS

Out of 14 patients, 13 had incontinence related to obstetric injuries while one was related to a cauda equina syndrome. All patients had a test procedure consisting of placement of temporary electrodes and a 2-week trial of external SNS. Ten patients noted a significant improvement in their continence and these 10 patients subsequently had a permanent SNS device implanted with an overall significant improvement in continence (P < 0.001) and quality of life (P < 0.01). There were no immediate postoperative complications and one late failure consisting of a lead fracture, which was replaced successfully. Four (29%) patients did not have a significant benefit from temporary SNS and two of these patients subsequently had a colostomy.

CONCLUSIONS

SNS offers improvement in continence and quality of life in patients with faecal incontinence whose only other option might otherwise be a permanent colostomy.

Is a morphologically intact anal sphincter necessary for success with sacral nerve modulation in patients with faecal incontinence?

OBJECTIVE

Sacral nerve modulation (SNM) for the treatment of faecal incontinence was originally performed in patients with an intact anal sphincter or after repair of a sphincter defect. There is evidence that SNM can be performed in patients with faecal incontinence and an anal sphincter defect.

METHOD

Two groups of patients were analysed retrospectively to determine whether SNM is as effective in patients with faecal incontinence associated with an anal sphincter defect as in those with a morphologically intact anal sphincter following anal repair (AR). Patients in group A had had an AR resulting in an intact anal sphincter ring. Group B included patients with a sphincter defect which was not primarily repaired. Both groups underwent SNM. All patients had undergone a test stimulation percutaneous nerve evaluation (PNE) followed by a subchronic test over 3 weeks. If the PNE was successful, a permanent SNM electrode was implanted. Follow-up visits for the successfully permanent implanted patients were scheduled at 1, 3, 6 and 12 months and annually thereafter.

RESULTS

Group A consisted of 20 (19 women) patients. Eighteen (90%) had a positive subchronic test stimulation. Twelve patients had a successful SNM implant during middle-term follow-up. Group B consisted of 20 women. The size of the defect in the anal sphincter varied between 17% and 33% of the anal circumference. Fourteen (70%) had a positive subchronic test stimulation. Twelve patients had a successful SNM implant during middle-term follow-up. In both groups, the mean number of incontinence episodes decreased significantly with SNM (test vs baseline: P = 0.0001, P = 0.0002). There was no significant difference in resting and squeeze pressures during SNM in group A, but in group B squeeze pressure had increased significantly at 24 months. Comparison of patient characteristics and outcome between groups A and B revealed no statistical differences.

CONCLUSION

A morphologically intact anal sphincter is not a prerequisite for success in the treatment of faecal incontinence with SNM. An anal sphincter defect of <33% of the circumference can be effectively treated primarily with SNM without repair.

Fecal incontinence: a review

Fecal incontinence (FI) is defined as the involuntary passage of fecal material through the anal canal. True incontinence must be differentiated from pseudo incontinence. FI is predominately a disease of the elderly or of institutional patients. Fecal incontinence in the nursing home population has been estimated at 47%. We provide a guide to appropriate clinical evaluation, diagnostic testing, and treatment of FI.

A systematic review of psychometric evidence and expert opinion regarding the assessment of faecal incontinence in older community-dwelling adults

OBJECTIVES

This review had two objectives: (i) to determine what is required in an assessment of faecal incontinence issues for older community-dwelling adults; and (ii) to determine the psychometric tools most effective for assessment of faecal incontinence in older community-dwelling adults.

INCLUSION CRITERIA

For the review of psychometric tools, studies were included if they were concerned with people living in the community, included a significant proportion of the sample aged 65 years or over, and either examined psychometric properties of assessment tools or assessed sensitivity of assessment tools to non-surgical interventions available in the community setting. For the review of expert opinion, the search was limited to expert opinion provided by an expert in faecal incontinence that related to community-based assessment. Only articles published in English were eligible for inclusion and no limits were placed on publication dates.

SEARCH STRATEGY

An initial search of Medline and CINAHL databases identified terminology frequently used in the literature with regard to assessment of faecal incontinence. An extensive search was then undertaken using all identified key words and index terms. The third step involved a search of reference lists and bibliographies of all relevant articles.

METHODOLOGICAL QUALITY

All identified studies that met the inclusion criteria were assessed for methodological validity in the case of studies considered for inclusion in the psychometric review. Validity of expert text was also assessed prior to it being included in the review.

RESULTS

The final search strategy identified approximately 7000 references. Full-text versions of 144 references were critically appraised for inclusion in the review. Of these, 25 sources were included in the review of expert opinion and 16 in the review of psychometric properties. In the review of expert opinion, 254 conclusions were extracted for synthesis. The 31 thematic categories were organised under five major themes:History-taking, bowel assessment, psychosocial aspects, physical examination and specialist referral. From the sources that survived critical appraisal, 52 conclusions relating to psychometric properties of assessment tools were derived. There was limited, if any, analysis of psychometric properties for the majority of assessment tools. The Wexner and Vaizey symptom severity scales demonstrated acceptable test-retest reliability and convergent validity. The Fecal Incontinence Quality of Life Scale (FIQLS) demonstrated reasonable reliability and good convergent and criterion-related validity. There was, however, some evidence questioning its discriminant validity.

CONCLUSIONS

This systematic review represents an important first stage in developing guidelines for assessment of faecal incontinence in community-dwelling older people. Assessment should be comprehensive in nature. Gaps in expert opinion are evident regarding issues such as assessment of cognitive decline and specialist referral. Continence advisors need to be appropriately trained in using and interpreting results from assessment tools and conducting physical examinations. Although studies in the review of psychometric properties suffer from limitations such as inadequate sample sizes, the Vaizey and Wexner scales would appear to be the tools of choice. The FIQLS is clearly the tool of choice at this stage for measuring faecal incontinence quality of life. Further validation of tests used in faecal incontinence assessments is required.

Risk factors for fecal and urinary incontinence after childbirth: the childbirth and pelvic symptoms study

OBJECTIVE

To identify risk factors for postpartum FI and UI.

METHODS

Secondary analysis of data from the CAPS study, which estimated the prevalence of postpartum FI and UI in primiparous women with clinically recognized anal sphincter tears after vaginal delivery, compared with women who delivered vaginally without recognized tears or by cesarean before labor. A total of 921 women were enrolled while in the hospital and 759 (82%) were interviewed by telephone 6 months postpartum. FI was assessed using the FISI and UI using the Medical, Epidemiological, and Social Aspects of Aging Questionnaire. FI risk factor analyses were conducted within each group, because of higher prevalence in the tear group. UI analyses were conducted with the groups combined.

RESULTS

In women with sphincter tears, FI at 6 months was associated with white race (OR 6.1, 95% CI 1.3-29.4), antenatal UI (OR 2.2, CI 1.1-4.3), 4th versus 3rd degree tear (OR 2.0, CI 1.0-4.0), older age at delivery (OR 1.6 per 5 yr, CI 1.2-2.1), and higher body mass index (BMI) (OR 1.3 per 5 kg/m(2), CI 1.0-1.7). No factors were associated with FI in the vaginal or cesarean control groups. Across all groups, risk factors for postpartum UI were antenatal UI (OR 3.5, CI 2.4-5.2), less education (OR 2.0, CI 1.4-2.8), and higher BMI (OR 1.2 per 5 kg/m(2), CI 1.1-1.4); cesarean delivery was protective (OR 0.5, CI 0.3-0.9).

CONCLUSIONS

Postpartum FI and UI are associated with few modifiable risk factors. However, the presence of antenatal UI and high BMI may help clinicians target at-risk women for early intervention.

Biofeedback for fecal incontinence: short-term outcomes of 513 consecutive patients and predictors of successful treatment

PURPOSE

Biofeedback is well established as a treatment for fecal incontinence but little is known about factors that may be associated with its effectiveness. This study assessed short-term outcomes, predictors of patients who completed treatment, and predictors of treatment success.

METHODS

This study was a retrospective review of consecutive patients treated with biofeedback at a tertiary referral colorectal clinic during ten years. Clinical, physiologic, and quality of life measures were collected prospectively at the time of treatment. Regression analysis was performed.

RESULTS

Of 513 patients, 385 (75 percent) completed the treatment program. Each outcome was improved for more than 70 percent of patients. Incontinence scores decreased by 32 percent (from 7.5 to 5.2 of 13), patient assessment of continence increased by 40 percent (from 5.3 to 3.2 of 10), quality of life improved by 89 percent (from 0.34 to 0.67 of 1.0), and maximum anal sphincter pressure increased by a mean 12 mmHg (14 percent; from 90 to 102 mmHg). Patients who did not complete treatment were younger, were more likely to be male, and had less severe incontinence. Treatment success was predicted by completion of all treatment sessions (odds ratio, 10.34; 95 percent confidence interval, 4.46-24.19), female gender (odds ratio, 4.11; 95 percent confidence interval, 1.04-7.5), older age (odds ratio, 1.02 per year; 95 percent confidence interval, 1-1.04), and more severe incontinence before treatment (odds ratio, 1.19 per unit increase in St. Mark's score; 95 percent confidence interval, 1.05-1.34).

CONCLUSIONS

More than 70 percent of patients in this large series demonstrated improved short-term outcomes. Treatment success was more likely in those who completed six training sessions, were female, older, or had more severe incontinence. Patients were less likely to complete treatment if they were male, younger, or had milder incontinence.

Accelerated partial breast irradiation in early-stage breast cancer

Whole-breast irradiation, as part of breast-conservation therapy (BCT), has well-established results, good cosmesis, and low toxicity. Results from the BCT trials suggest that the risk for ipsilateral breast cancer recurrence resides within close proximity to the original tumor site. This leads investigators to consider the role of an accelerated and more tumor bed-focused course of radiotherapy. Accelerated partial-breast irradiation (APBI) involves treating a limited volume of breast tissue, with dose of irradiation per fraction increased and the treatment time course decreased. Four currently available methods of APBI are interstitial brachytherapy, intracavitary brachytherapy, intraoperative radiotherapy, and three-dimensional conformal external-beam radiotherapy. Patient selection is critical. This review article presents some preliminary clinical observations and limitations that suggest a potential role for APBI as a more user-friendly mode for delivering radiotherapy after lumpectomy for early breast cancer.

Magnetic resonance-based female pelvic anatomy as relevant for maternal childbirth injury simulations

The objectives of the study are to review the female pelvic floor anatomy relevant to childbirth simulations, to discuss available methods for clinical evaluation of female pelvic floor function, and to review the variation in pelvic floor changes after vaginal childbirth. A high-resolution magnetic resonance (MR) data set from an asymptomatic nullipara was used to illustrate the MR anatomy of the female pelvic floor. Manual segmentation was performed and three-dimensional reconstructions of the pelvic floor structures were generated, which were used to illustrate the 3D anatomy of the pelvic floor. Variation in the post partum appearance of the levator ani muscles is illustrated using other 2D MR data sets, which depict unilateral and bilateral disruptions in the puborectalis portion of levator ani, as well as shape variations, which may be seen in the post partum levator. The clinical evaluation of the pelvic floor is then reviewed. The female pelvis is composed of a bony scaffold, from which the pelvic floor muscles (obturator internus, levator ani) are suspended. The rectum fits in a midline groove in the levator ani. The vagina is suspended across the midline, attaching bilaterally to the obturator and levator ani. The vagina supports the bladder and urethra. MR studies have demonstrated disruptions in levator ani attachments after vaginal childbirth. Such disruptions are rare in women who have not given birth vaginally. Changes to the neuromuscular apparatus of the pelvic floor can also be demonstrated after vaginal delivery. The combination of childbirth-related anatomic and neurological injury to the pelvic floor may be associated with pelvic floor dysfunction (PFD). These changes are difficult to study in vivo but may be studied through simulations. Appropriate consideration of clinical anatomy is important in these simulations.