Fecal incontinence: mechanisms and management

Sensory brain activation during rectal balloon distention: a pilot study in healthy volunteers to assess safety and feasibility at 1.5T

OBJECTIVE

Although increasing evidence suggests a central mechanism of action for sacral neuromodulation, the exact mechanism remains unclear. We set up a scanning paradigm to measure brain activation related to various stages of rectal filling using rectal balloon distention.

MATERIALS AND METHODS

Six healthy volunteers underwent rectal balloon distention during MRI scanning at a 1.5T scanner with a Tx/Rx head coil. MR images were collected at four levels of distention: empty balloon (EB), first sensation volume (FSV), desire to defecate volume (DDV), maximum tolerable volume (MTV). Data were analyzed using BrainVoyager 20.4. Whole brain and ROI-based fixed-effects general linear model analyses were performed on the fMRI time-course data from all participants.

RESULTS

Rectal filling until FSV evoked the most blood-oxygen-level-dependent responses in several clusters throughout the cortex, followed by the responses evoked by rectal filling until DDV. Interestingly, rectal filling until MTV evoked negative responses compared to baseline throughout the cortex. No negative side effects were found.

DISCUSSION

This study shows that a standardized paradigm for functional MRI combined with rectal filling is feasible and safe in healthy volunteers and is ready to be used in fecal incontinent patients to assess whether their brain activity differs from healthy controls.

A Prediction Model of Defecation Based on BP Neural Network and Bowel Sound Signal Features

(1) Background: Incontinence and its complications pose great difficulties in the care of the disabled. Currently, invasive incontinence monitoring methods are too invasive, expensive, and bulky to be widely used. Compared with previous methods, bowel sound monitoring is the most commonly used non-invasive monitoring method for intestinal diseases and may even provide clinical support for doctors. (2) Methods: This paper proposes a method based on the features of bowel sound signals, which uses a BP classification neural network to predict bowel defecation and realizes a non-invasive collection of physiological signals. Firstly, according to the physiological function of human defecation, bowel sound signals were selected for monitoring and analysis before defecation, and a portable non-invasive bowel sound collection system was built. Then, the detector algorithm based on iterative kurtosis and the signal processing method based on Kalman filter was used to process the signal to remove the aliasing noise in the bowel sound signal, and feature extraction was carried out in the time domain, frequency domain, and time-frequency domain. Finally, BP neural network was selected to build a classification training method for the features of bowel sound signals. (3) Results: Experimental results based on real data sets show that the proposed method can converge to a stable state and achieve a prediction accuracy of 88.71% in 232 records, which is better than other classification methods. (4) Conclusions: The result indicates that the proposed method could provide a high-precision defecation prediction result for patients with fecal incontinence, so as to prepare for defecation in advance.

Effects of an anal fistula plug on anal function after surgery for treatment of a trans-sphincteric anal fistula

PURPOSE

The aim of this study was to evaluate the anal function in patients with trans-sphincteric anal fistulas who underwent an anal fistula plug procedure, and analyze risk factors that might affect post-operative anal function.

METHODS

This was an observational, retrospective study of patients diagnosed with trans-sphincteric anal fistulas and initially underwent anal fistula plug procedures between August 2008 and September 2012 at our institute. The analysis includes clinical characteristics, anal fistula healing, and the Wexner score for pre- and post-operative anal function (0 = no incontinence to 20 = complete incontinence).

RESULTS

A total of 123 patients who had an adequate follow-up in the end were included. The median duration of follow-up was 8 years (range 72-121 months). The overall healing rate was 56% (69/123), and 33 (26.8%) patients had decreased anal function after surgery. The post-operative Wexner score on anal function was significantly higher than that before the operation (p < 0.001), as well as scores of gas, liquid stool, solid stool incontinence, and alteration in lifestyle (p < 0.05). Based on multiple logistic regression analysis, a high body mass index (p < 0.001) and long distance between the external opening and anal verge (p = 0.003) were significantly associated with a decline in post-operative anal function.

CONCLUSIONS

As a sphincter-preserving technique for the treatment of anal fistulas, the anal fistula plug procedure might impair the anal function. Especially for patients with obesity or long distance between the external opening of anal fistula and anal verge, the reduced anal function is more likely to occur after treatment with anal fistula plug therapy.

Continence: Bowel and Bladder and Physical Function Decline in Women

Purpose of review

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

Recent findings

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

Summary

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

Acupuncture for fecal incontinence: Protocol for a systematic review and data mining

BACKGROUND

Fecal incontinence is a socially and emotionally destructive condition that has a negative impact on personal image, self-confidence, and quality of life. Acupuncture is commonly used to treat chronic conditions, including fecal incontinence. However, no relevant systematic review or meta-analysis has been designed to evaluate the effects of acupuncture on fecal incontinence.

METHODS

We will identify relevant randomized controlled trials (RCTs) from the Cochrane Library, Medline, Embase, PubMed, Springer, Web of Science, China National Knowledge Infrastructure, VIP Chinese Science and Technology Journals Database, Wanfang database, and clinical trial registration center from their inception to February 28, 2019. The primary outcome measures will be clinical effective rate, functional outcomes, and quality of life. Data that meets the inclusion criteria will be extracted and analyzed using RevMan V.5.3 software. Two reviewers will evaluate the studies using the Cochrane Collaboration risk of bias tool. Publication bias will be assessed by funnel plots, Egger test, and Begg test using the Stata software. Acupoints characteristics will be analyzed by Traditional Chinese Medicine inheritance support system.

RESULTS

This study will analyze the clinical effective rate, functional outcomes, quality of life, daily average number of fecal incontinence, and effective prescriptions of acupuncture for patients with fecal incontinence.

CONCLUSION

Our findings will provide evidence for the effectiveness and potential treatment prescriptions of acupuncture for patients with fecal incontinence.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD42019119680.

Eliciting Help-Seeking Behaviors in Patients With Fecal Incontinence: Supporting Timely Access to Treatment

People with fecal incontinence (FI) symptoms often do not report their symptoms to their care providers, which may adversely impact their quality of life. Although the differential diagnosis for the cause of an individual's FI symptoms can be done by a family doctor, nurse practitioner, or a specialist, many other healthcare professionals have the training and education to competently screen patients for FI risk factors. Those individuals identified with FI symptoms can be supported to disclose this information to their healthcare professional in a timely manner. Healthcare professionals have a responsibility to encourage patients to seek medical treatment in order to ensure an accurate diagnosis for their FI symptoms, and to support clients through the process of managing symptoms including adhering to care plans to mitigate modifiable causes of FI. When clients actively seek medical help, it is referred to as help-seeking behavior. Given the sensitive nature of FI, with the associated stigma and taboo surrounding the topic, healthcare providers must conscientiously work to support each client with sensitivity and self-awareness.

What about clonidine for diarrhoea? A systematic review and meta-analysis of its effect in humans

BACKGROUND

Clonidine is considered an alternative treatment for refractory diarrhoea. The evidence in the literature is scarce and not conclusive. The present paper's purpose is to gather available evidence and provide a systematic answer regarding the effectiveness of clonidine for diarrhoea.

METHOD

We performed a systematic review of clonidine and its effect on diarrhoea. Meta-analysis was performed with a random effects model of the standardized mean difference (SMD) or the weighted mean difference and heterogeneity was quantified with I (2) and publication bias was assessed with Egger's and Begg's test. Subgroup analyses and meta-regression were performed to investigate sources of heterogeneity. Any empirical study describing use of clonidine for diarrhoea in humans independent of age was included. For the meta-analysis, papers had to provide sufficient data to produce an effect measure, while case reports were not included in the meta-analysis and are discussed narratively only.

RESULTS

A total of 24 trials and seven case reports were identified. Clonidine (median dose 300 μg/day) has been used for treatment of diarrhoea in irritable bowel syndrome, faecal incontinence, diabetes, withdrawal-associated diarrhoea, intestinal failure, neuroendocrine tumours and cholera; studies were also performed on healthy volunteers. Results indicate a strong effect of clonidine on diarrhoea (SMD = -1.02, 95% confidence interval [CI] -1.46 to -0.58) with a decrease of stool volume by 0.97 l/day, stool frequency by 0.4 times/day and increase in transit time by 31 minutes. In a sensitivity analysis of studies with functional diarrhoea and sample size over 10 subjects, the effect was similar -0.99 (95% CI -1.54 to -0.43). There is however significant heterogeneity and publication bias. Heterogeneity decreased in subgroup analyses by condition but not with other factors examined. A limitation of the present study includes small study effects.

CONCLUSION

Clonidine is effective for treatment of diarrhoea and should be considered as an alternative when all other medications have failed.

Incontinence-associated dermatitis: a cross-sectional prevalence study in the Australian acute care hospital setting

The purpose of this cross-sectional study was to identify the prevalence of incontinence and incontinence-associated dermatitis (IAD) in Australian acute care patients and to describe the products worn to manage incontinence, and those provided at the bedside for perineal skin care. Data on 376 inpatients were collected over 2 days at a major Australian teaching hospital. The mean age of the sample group was 62 years and 52% of the patients were male. The prevalence rate of incontinence was 24% (91/376). Urinary incontinence was significantly more prevalent in females (10%) than males (6%) (χ(2)  = 4·458, df = 1, P = 0·035). IAD occurred in 10% (38/376) of the sample group, with 42% (38/91) of incontinent patients having IAD. Semi-formed and liquid stool were associated with IAD (χ(2)  = 5·520, df = 1, P = 0·027). Clinical indication of fungal infection was present in 32% (12/38) of patients with IAD. Absorbent disposable briefs were the most common incontinence aids used (80%, 70/91), with soap/water and disposable washcloths being the clean-up products most commonly available (60%, 55/91) at the bedside. Further data are needed to validate this high prevalence. Studies that address prevention of IAD and the effectiveness of management strategies are also needed.

Perineal retraining improves conservative treatment for faecal incontinence: a multicentre randomized study

BACKGROUND

Anal incontinence is a frequent complaint that profoundly affects quality of life. Our aim was to determine whether perineal retraining gives additional benefits to standard medical treatment.

METHODS

Patients with anal incontinence and a Wexner score >4 were randomly assigned to standard conservative treatment (control) or perineal retraining, including biofeedback, in addition to standard treatments (biofeedback). Diaries, self-administered questionnaires and satisfaction scores quantified the benefits. Self-evaluated improvement was the primary outcome measure. A score ≥3 (in an improvement scale from -5 to +5) defined success.

RESULTS

Overall, 157 patients were included; 80 in the control group (75% females, mean age 60.1 ± 13.2 years) and 77 in the biofeedback group (79% females, mean age 61.9 ± 10.2 years). After a 4-month follow-up, the success rate was significantly higher in the biofeedback group (57% versus 37%; p<0.021). In the biofeedback group, daily stool frequency, leakage, and faecal urgency significantly decreased, and daily non-urgent perception of stool increased. Conversely, symptomatic scores and quality of life scales did not significantly differ between groups. In a multivariate model, the adjusted odds ratio showed that perineal retraining was significantly associated with a higher chance of self-rated improvement (adjusted Odd Ratio [95%CI]: 2.34 [1.14-4.80]; p=0.021).

CONCLUSIONS

Perineal retraining offers a moderate but significant benefit for patients suffering from anal incontinence.

Surgical therapies for fecal incontinence

PURPOSE OF REVIEW

Fecal incontinence is a significant source of morbidity and decreased quality of life (QOL) for many. Until recent years, few therapies beyond medical management were available for patients. Surgical treatment of fecal incontinence has evolved from colostomy and direct repair of muscle defects to interventional techniques such as nerve stimulation and bulking agents. We review the most recent surgical options for the treatment of fecal incontinence within the context of established therapies.

RECENT FINDINGS

Overlapping sphincteroplasty is an established therapy that improves continence and QOL, although results deteriorate over time. Implanted artificial bowel sphincter has a 100% complication rate and 80% are explanted over time. Sacral nerve stimulation has minimal risk and more durable long-term improvement in continence. Less invasive versions of nerve stimulation are being researched. Injectable biomaterials have shown some promise, although durability of results is not clear. Novel therapies, including muscle cell transfer and pelvic slings are currently being investigated.

SUMMARY

Surgical therapies for fecal incontinence continue to evolve and show promise in improving QOL with a lower risk profile. Effective valuation of these therapies is currently limited by heterogeneous studies, short duration of follow up, and inconsistent outcome measures.

Functional disorders of the gastrointestinal tract: Cost effectiveness review

BACKGROUND

The project aim was to review current cost-effectiveness research for each functional gastrointestinal disorder, as defined by the Rome III classification system.

METHODS

Biomedical databases were searched for articles with the functional gastrointestinal disorders and their pseudonyms included in the title, abstract, or medical subject headings, plus the terms benefit, cost, effectiveness, outcomes, test, utility, or utilization in any search field.

RESULTS

Highly prevalent conditions such as dyspepsia and irritable bowel syndrome have advanced cost-effectiveness analyses including cost-utility studies that have helped support current management guidelines. The rarer functional gastrointestinal disorders have few or no published cost-effectiveness analyses, but the Rome III classification system provides a framework for identifying the specific cost data or outcomes measures available or needed for future research.

CONCLUSIONS

The Rome process has provided a useful system for defining the functional gastrointestinal disorders and identifying specific clinical questions to be examined using cost-effectiveness analysis techniques.

Percutaneous posterior tibial nerve stimulation (PPTNS) in faecal incontinence associated with an anal sphincter lesion: results of a prospective study

PURPOSE

Establish the efficacy of posterior tibial nerve stimulation in treating faecal incontinence associated to sphincter defect.

METHODS

Prospective study that included patients with faecal incontinence associated to sphincter lesions between 90 and 180°. Clinical anamnesis, physical examination, reverse visual analogic scale, incontinence diary and Wexner score were recorded at baseline and 6 months. Anal manometry was realized at baseline and 6 months. Subjects underwent one 30-min session every week for 12 consecutive weeks and was continued with 6 additional sessions every 2 weeks.

RESULTS

Sixteen patients were analysed, 15 women and 1 men, with a mean age of 56.5 years. The incontinence were obstetric origin (50%) and perineal surgeries (50%). Four patients who did not continue with the second stage. Referring to the retention time, at baseline 12 patients (75%) did not bear even 1 min. At 6 months the retention time was <1 min in only 2 patients (p = 0.008). Median Wexner baseline values were 10; at 6 months decrease to 5 (p = 0.006). The visual analogical scale (VAS) increased from 6 to 7.5 (p > 0.05). After 6 months, maximum resting pressure increased from 40.9 to 51 mmHg (p < 0.001) and maximum squeeze pressure from 82.5 to 94 mmHg (p < 0.001).

CONCLUSION

PTNS is an effective treatment for faecal incontinence associated to sphincter lesions because the number of incontinence episodes per week, the Wexner Score, the ability to defer defaecation and the manometric determinations improved significantly.

Faecal soiling: pathophysiology of postdefaecatory incontinence

AIM

Passive postdefaecatory incontinence is poorly understood and yet is an important clinical problem. The aim of this study was to characterize the pathophysiology of postdefaecatory incontinence in patients affected by faecal soiling.

METHOD

Seventy-two patients (30 women, age range 49-79 years; 42 men, age range, 53-75 years) affected by faecal passive incontinence with faecal soiling were included in the study. Two patient groups were identified: Group 1 comprised 42 patients with postdefaecatory incontinence and Group 2 had 30 patients without incontinence after bowel movements. After a preliminary clinical evaluation, including the Faecal Incontinence Severity Index (FISI) score and the obstructed defaecation syndrome (ODS) score, all patients of Groups 1 and 2 were studied by means of endoanal ultrasound and anorectal manometry. The results were compared with those from 20 healthy control subjects.

RESULTS

A significantly higher ODS score was found in Group 1 (P < 0.001). Endoanal ultrasound revealed a significantly diffuse thinning of the internal anal sphincter (IAS) in Group 2 (P < 0.02) with a linear relationship between signs of IAS atrophy and the FISI score (ρs 0.78; P < 0.03). Anal resting pressure (Pmax and Pm ) was significantly lower in Group 2 (P < 0.04). The straining test was considered positive in 30 (71.4%) patients in Group 1, significantly greater than in Group 2 (P < 0.01). A significantly higher conscious rectal sensitivity threshold (CRST) was found in Group 1 patients (P < 0.01).

CONCLUSION

The ODS score, a positive straining test and high CRST values suggest that postdefaecatory incontinence is secondary to impaired defaecation.

Racial differences in fecal incontinence in community-dwelling women from the EPI study

OBJECTIVES

Despite its prevalence and associated distress, fecal incontinence (FI) is not well understood. There are limited data regarding associations between FI and race. The goal of this study was to estimate the prevalence of FI, and to secondarily identify demographic, lifestyle, and medical factors associated with FI, especially with regard to race.

METHODS

This was a planned secondary analysis of a population-based cross-sectional telephone interview survey of 2812 black and white community-dwelling women living in southeastern Michigan. The primary outcome measured was the prevalence of self-reported FI, defined as any loss of stool during the previous 12 months. Logistic regression modeling was used to identify characteristics independently associated with FI.

RESULTS

Of the subjects, 16.7% reported FI in the previous year. Fecal incontinence was approximately twice as common in white women (20%) as black women (11%). Factors associated with FI differed between the 2 races, although its prevalence in both racial groups increases with higher numbers of medical comorbidities, increased frequency of bowel movements per week, and depression.

CONCLUSIONS

One in 6 women report FI, although it occurs one-half as often in black as in white women. Although there are common characteristics shared by women with FI in both racial groups, white women experience FI in complex with other pelvic floor disorders. For black women, FI is an isolated pelvic floor disorder associated with mobility impairment.

Tissue engineering for neuromuscular disorders of the gastrointestinal tract

The digestive tract is designed for the optimal processing of food that nourishes all organ systems. The esophagus, stomach, small bowel, and colon are sophisticated neuromuscular tubes with specialized sphincters that transport ingested food-stuffs from one region to another. Peristaltic contractions move ingested solids and liquids from the esophagus into the stomach; the stomach mixes the ingested nutrients into chyme and empties chyme from the stomach into the duodenum. The to-and-fro movement of the small bowel maximizes absorption of fat, protein, and carbohydrates. Peristaltic contractions are necessary for colon function and defecation.