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Eccles A, Parsons J, Bick D, Keighley MR, Clements A, Cornish J, Embleton S, McNiven A, Seers K, Hillman SC. GP's role in supporting women with anal incontinence after childbirth injury: a qualitative study. Br J Gen Pract 2024:BJGP.2023.0356. [PMID: 38359950 PMCID: PMC11181556 DOI: 10.3399/bjgp.2023.0356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 01/03/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Obstetric anal sphincter injury is the most common cause of anal incontinence for women, which often has profound impacts on women's lives. GPs offer a first line of contact for many women, but we know that very few women experiencing anal incontinence postnatally report discussing it with their GPs. AIM To identify key ways in which GPs can support women with anal incontinence caused by childbirth injuries. DESIGN AND SETTING A qualitative study investigating women's experiences with their GP, and GPs' perspectives about providing such care. METHOD This qualitative study combined two phases: first, a series of in-depth semi-structured interviews with women experiencing anal incontinence caused by childbirth injuries (n = 41); and second, focus groups with GPs (n = 13) stratified by experience. Thematic analysis was conducted and relevant themes from across the two datasets were examined. RESULTS Mediating factors in GP care for women with anal incontinence caused by childbirth injuries centred around three key themes: the role of the GP, access and pathways, and communication. CONCLUSION The findings demonstrate multifactorial challenges in identifying the problem and supporting women experiencing anal incontinence after childbirth injury in primary care settings. Many GPs lacked confidence in their role in supporting women, and women were often reluctant to seek help. Those women who did seek help often experienced frustrations consulting with their GPs. In a context where women are often reluctant to ask for help, their concerns are not always taken seriously, and where GPs do not routinely ask about anal incontinence, potential anal incontinence after childbirth injury appears to be often missed in a primary care setting.
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Affiliation(s)
- Abi Eccles
- Warwick Applied Health, Warwick Medical School, University of Warwick, Warwick
| | - Joanne Parsons
- Warwick Applied Health, Warwick Medical School, University of Warwick, Warwick
| | - Debra Bick
- Warwick Clinical Trials Unit, University of Warwick, Warwick
| | | | | | - Julie Cornish
- Department of Colorectal Surgery, Cardiff and Vale University Health Board, Cardiff
| | | | - Abigail McNiven
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Kate Seers
- Warwick Applied Health, Warwick Medical School, University of Warwick, Warwick
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Jouanny C, Abhyankar P, Maxwell M. A mixed methods systematic literature review of barriers and facilitators to help-seeking among women with stigmatised pelvic health symptoms. BMC Womens Health 2024; 24:217. [PMID: 38570870 PMCID: PMC10993589 DOI: 10.1186/s12905-024-03063-6] [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: 10/24/2023] [Accepted: 03/29/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND Women's pelvic health is a globally important subject, included in international and United Kingdom health policies, emphasising the importance of improving information and access to pelvic health services. Consequences of pelvic symptoms are intimate, personal, and varied, often causing embarrassment and shame, affecting women's quality of life and wellbeing. AIM To understand the experience of seeking healthcare for stigmatised pelvic health symptoms by synthesising all types of published primary research and mapping the results to behavioural theory, to identify potential targets for intervention. METHODS Systematic search of MEDLINE, CINAHL, PsycINFO, SocINDEX, PubMED databases, CDSR and CENTRAL registers, from inception to May 2023 for all types of research capturing women's views and experiences of seeking help with stigmatised urogenital and bowel symptoms. Studies only reporting prevalence, predictors of help-seeking, non-health related help-seeking, or written in languages other than English, German, French, Spanish and Swedish were excluded. Reference checking and forward citation searching for all included studies was performed. A results-based synthesis approach was used to integrate quantitative and qualitative data. Themes were mapped to the Common-Sense model and Candidacy framework. The Mixed Methods Appraisal Tool was used for critical appraisal. Grading of Recommendations Assessment, Development and Evaluation - Confidence in Evidence from Reviews of Qualitative research for assessing certainty of review findings. RESULTS 86 studies representing over 20,000 women from 24 high income countries were included. Confidence was high that barriers to help-seeking were similar across all study types and pelvic symptoms: stigma, lack of knowledge, women's perception that clinicians dismissed their symptoms, and associated normalising and deprioritising of low bother symptoms. Supportive clinicians and increased knowledge were key facilitators. CONCLUSIONS Using the Common-Sense Model to explore women's help-seeking behaviour with stigmatised pelvic symptoms reveals problems with cognitive representation of symptom identity, emotional representations of embarrassment and shame, and a subjective norm that women believe their symptoms will be trivialised by clinicians. Together these barriers frustrate women's identification of their candidacy for healthcare. Addressing these issues through behavioural change interventions for women and clinicians, will help to achieve universal access to pelvic healthcare services (United Nations Sustainable Development Goal 3.7). SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42021256956.
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Affiliation(s)
- Clare Jouanny
- Faculty of Health Sciences and Sport, University of Stirling, Stirling, Scotland.
| | - Purva Abhyankar
- Department of Psychology, University of Stirling, Stirling, Scotland
| | - Margaret Maxwell
- The Nursing, Midwifery and Allied Health Professions Research Unit, University of Stirling, Stirling, Scotland
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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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4
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Garoufalia Z, Gefen R, Emile SH, Silva-Alvarenga E, Freund MR, Horesh N, Wexner SD. Outcomes of graciloplasty in the treatment of fecal incontinence: a systematic review and meta-analysis of the literature. Tech Coloproctol 2023; 27:429-441. [PMID: 36479654 DOI: 10.1007/s10151-022-02734-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 11/14/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patients with refractory fecal incontinence symptoms can be treated with several surgical procedures including graciloplasty. Reported outcomes and morbidity rates of this procedure are highly variable. The aim of this study was to assess continence rate and safety of dynamic and adynamic graciloplasty. METHODS PubMed and Google Scholar databases were systematically searched from inception until January 2022 according to preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Reviews, animal studies, studies with patients < 18 years or < 10 patients, with no success rate reported or non-English text, were excluded. Main outcome measures were overall continence and morbidity rates of each technique. RESULTS Fourteen studies were identified, incorporating a total of 450 patients (337 females), published between 1980 and 2021. Most common etiology of incontinence (35.5%-n = 160) was obstetric trauma followed by anorectal trauma (20%-n = 90). The weighted mean rate of continence after dynamic graciloplasty was 69.1% (95% CI 0.53-0.84%, I2 = 90%) compared to 71% (95% CI 0.54-0.87, I2 = 82.5%) after adynamic. Although the weighted mean short-term complication rate was lower in the dynamic group (26% versus 40%), when focusing on complications requiring intervention under general anesthesia, there was a much higher incidence (43.4% versus 10.5%) in the dynamic group. The weighted mean rate of long-term complications was 59.4% (95% CI 0.13-1.04%, I2 = 97.7%) in the dynamic group, almost twice higher than in the adynamic group [30% (95% CI - 0.03 to 0.63), I2 = 95.8%]. Median follow-up ranged from 1 to 13 years. CONCLUSIONS Our data suggest that graciloplasty may be considered for incontinent patients. Dynamic graciloplasty may harbor higher risk for reoperation and complications compared to adynamic. The fact that the functional results between adynamic and dynamic graciloplasty are equivalent and the morbidity rate of adynamic graciloplasty is significantly lower reinforce the graciloplasty as an option to treat appropriately selected patients with fecal incontinence.
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Affiliation(s)
- Z Garoufalia
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - R Gefen
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
- Department of General Surgery, Faculty of Medicine, Hadassah Medical Organization, Hebrew University of Jerusalem, Jerusalem, Israel
| | - S H Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura, Egypt
| | - E Silva-Alvarenga
- Martin Health at Tradition HealthPark Two, Cleveland Clinic Florida, Weston, FL, USA
| | - M R Freund
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
- Department of General Surgery, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - N Horesh
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
- Department of Surgery and Transplantations, Sheba Medical Center, Ramat Gan, Israel
| | - S D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA.
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Differences in Anorectal Manometry Values Among Women With Fecal Incontinence in a Racially, Ethnically, and Socioeconomically Diverse Population. UROGYNECOLOGY (HAGERSTOWN, MD.) 2023; 29:244-251. [PMID: 36735440 DOI: 10.1097/spv.0000000000001324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
IMPORTANCE Anorectal manometry (ARM) is a valuable diagnostic and therapeutic tool that can both aid in identifying mechanisms contributing to fecal incontinence (FI) and inform management strategies. Consensus on standard reference range values has not been established, and women of varying racial and ethnic backgrounds are not well-represented in the current literature. OBJECTIVE We aimed to compare ARM values between women of different racial and ethnic groups with FI. STUDY DESIGN We conducted a retrospective cross-sectional study of women with FI who underwent ARM at a tertiary health system in an urban underserved community between 2016 and 2021. Demographic information and ARM values were collected from the medical record. Socioeconomic status (SES) was represented by the percent of the population living below the poverty line according to zip code using U.S. census data. Anorectal manometry values were compared between racial and ethnic groups, and multivariable logistic regression was conducted to control for patient characteristics. RESULTS Fifty-eight women were included in the analysis: 33% Hispanic, 22% Black, and 45% White. Hispanic and Black women had higher body mass index and higher rates of diabetes and loose stools and were of significantly lower SES compared with White women. Black and Hispanic women had significantly lower thresholds for volume at first sensation and higher mean anal squeeze pressure. Differences were maintained after controlling for body mass index, diabetes, SES, and diarrhea (P = 0.03 and P = 0.01, respectively). Other ARM values were not significantly different between groups. CONCLUSIONS Racial and ethnic differences in ARM values among women with FI exist. Further studies are needed to determine whether these differences have an impact on symptom severity, treatment selection and outcomes, and patient satisfaction.
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Swier RM, Siebrasse A, Coscia E, Peery AF. Diet in Benign Colonic Disorders: A Narrative Review. Clin Ther 2022; 44:657-670. [DOI: 10.1016/j.clinthera.2022.03.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/16/2022] [Accepted: 03/16/2022] [Indexed: 12/14/2022]
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Menees S, Chey WD. Fecal Incontinence: Pathogenesis, Diagnosis, and Updated Treatment Strategies. Gastroenterol Clin North Am 2022; 51:71-91. [PMID: 35135666 DOI: 10.1016/j.gtc.2021.10.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Fecal incontinence (FI) is defined as the involuntary loss or passage of solid or liquid stool in patients. FI is a common and debilitating condition in men and women. The incidence increases with age and also often goes unreported to health care providers. It is crucial that providers ask at-risk patients about possible symptoms. Evaluation and management is tailored to specific symptoms and characteristics of the incontinence. If conservative methods fail to improve symptoms, then other surgical options are considered, such as sacral nerve stimulation and anal sphincter augmentation. This review provides an update on current and future therapies.
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Affiliation(s)
- Stacy Menees
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine Health System, Ann Arbor, MI, USA; Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.
| | - William D Chey
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine Health System, Ann Arbor, MI, USA
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8
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Livovsky DM, Koslowsky B, Goldin E, Lysy J. External kinesiology tape for improvement in fecal incontinence symptom bother in women: a pilot study. Int Urogynecol J 2022; 33:2859-2868. [PMID: 35039916 DOI: 10.1007/s00192-021-05050-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 11/14/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Fecal incontinence is a debilitating condition with a devastating impact on quality of life. Using a commercially available kinesiology band we developed an anal tape to be applied to the anus with the aim to determine its impact on symptom bother and quality of life. METHODS Four-week prospective, self-controlled, pilot study of patients with FI. The primary outcome was improvement in any of the four domains (lifestyle, coping/behavior, depression/self-perception, embarrassment) evaluated by the "Fecal Incontinence Quality of Life Scale." Secondary outcomes included improvement in frequency of incontinence events and safety. Days 0-14 served as control period and days 15-28 as study period. Patients were asked to rate their satisfaction and willingness to use the device in the future using a 10-cm continuous visual analog scale. RESULTS Twenty patients completed the study. Median age was 64 years; all patients were females. Significant improvements were observed in all domains of the Fecal Incontinence Quality of Life Scale from baseline to day 28 (p < 0.001 for all) and in three of four domains between day 15 and 28 (p < 0.04) but not between days 1 and 14. Five patients (25%) had a ≥ 50% improvement in incontinence events. Patients reported satisfaction and willingness to use the anal tape in the future. Other than mild difficulty to remove the anal tape, no adverse events were reported. CONCLUSIONS In this small pilot study, the use of the anal tape was safe and effective. The primary outcome of significant improvement in quality of life was achieved ( ClinicalTrials.gov ID:NCT02989545). PUBLIC TRIAL REGISTRY ClinicalTrials.gov identifier NCT02989545. https://clinicaltrials.gov/ct2/show/NCT02989545.
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Affiliation(s)
- Dan M Livovsky
- Digestive Diseases Institute, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
- The Neurogastroenterology and Pelvic Floor Unit, Digestive Diseases Institute, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Israel, 12 Baiyt St., Jerusalem, Israel.
| | - Benjamin Koslowsky
- Digestive Diseases Institute, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Eran Goldin
- Digestive Diseases Institute, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Joseph Lysy
- Digestive Diseases Institute, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- The Neurogastroenterology and Pelvic Floor Unit, Digestive Diseases Institute, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Israel, 12 Baiyt St., Jerusalem, Israel
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Abstract
OBJECTIVES This study aimed to understand the potential reach of continence promotion intervention formats among incontinent women. METHODS The Survey of the Health of Wisconsin conducts household interviews on a population-based sample. In 2016, 399 adult women were asked about incontinence and likelihood of participation in continence promotion via 3 formats: single lecture, interactive 3-session workshop, or online. Descriptive analyses compared women likely versus unlikely to participate in continence promotion. To understand format preferences, modified grounded theory was used to conduct and analyze telephone interviews. RESULTS One hundred eighty-seven (76%) of 246 incontinent women reported being likely to attend continence promotion: 111 (45%) for a single lecture, 43 (17%) for an interactive 3-session workshop, and 156 (64%) for an online program. Obesity, older age, nonwhite race, prior health program participation, and Internet use for health information were associated with reported continence promotion participation. Cited advantages of a single lecture included convenience and ability to ask questions. A workshop offered accountability, hands-on learning, and opportunity to learn from others; online format offered privacy, convenience, and self-directed learning. CONCLUSIONS Most incontinent women are willing to participate in continence promotion, especially online.
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10
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Tucker J, Steen M, Briley A. Enhancing the identification of anal incontinence in women of reproductive age. Nurs Stand 2021; 36:71-76. [PMID: 33870661 DOI: 10.7748/ns.2021.e11735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2021] [Indexed: 11/09/2022]
Abstract
Anal incontinence is an unpredictable and debilitating condition that can significantly reduce quality of life. Symptoms include the involuntary loss of solid and/or liquid stool, flatus incontinence and rectal urgency. Pregnancy and childbirth are two major factors that increase the risk of anal incontinence in women of reproductive age. Women at high risk of anal incontinence include those with a known history of the condition and those who have experienced severe perineal trauma, particularly after injury to the anal sphincters (third-degree and fourth-degree tears). Routine screening for anal incontinence of women in high-risk groups during pregnancy and after childbirth appears to be limited in clinical practice. This article discusses the potential benefits of screening for anal incontinence, outlines the factors that inhibit and enable screening, describes current bowel screening tools and their limitations, and explores how the identification of anal incontinence in women of reproductive age could be improved.
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Affiliation(s)
| | - Mary Steen
- professorial lead for maternal and family health, Clinical and Health Sciences, University of South Australia, Adelaide, Australia
| | - Annette Briley
- College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
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11
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Wexner SD. Further validation of the Wexner Incontinence Score: A note of appreciation and gratitude. Surgery 2021; 170:53-54. [PMID: 33863582 DOI: 10.1016/j.surg.2021.02.039] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Abstract
OBJECTIVES Although the impact of stigma is known for women with urinary incontinence, it has not been well studied among the full spectrum of pelvic floor disorders. This study quantifies the level of stigma among women presenting for urogynecologic care and tests the hypothesis that stigma related to pelvic floor disorders results in a delay in care seeking for these problems. METHODS Women presenting for new patient visits (N = 523) in university medical center-based urogynecology clinics completed 2 anonymous questionnaires (Stigma Scale for Chronic Illnesses 8-item version and Pelvic Floor Bother Questionnaire) before their visit. The Kruskal-Wallis test was used to compare the distributions of stigma scores. Logistic regression was used to model factors associated with a delay in seeking care. Spearman correlation was used to determine whether there was an association between stigma and bother scores. RESULTS Median stigma score was significantly higher for those presenting with complaints of urine leakage (P = 0.015), accidental bowel leakage (P < 0.001), and constipation (P < 0.001) compared with women without these symptoms. Women presenting with accidental bowel leakage had the highest median stigma score, and those presenting with pelvic organ prolapse had the lowest. Total stigma score had a moderately positive correlation (r = 0.5, P < 0.001) with bother score. In a logistic regression model, higher stigma score was associated with a decreased likelihood of waiting 1 year or more to seek care (odds ratio = 0.92, 95% confidence interval = 0.86-0.98). CONCLUSIONS Pelvic floor disorders carry varying levels of stigma. Women who feel more stigmatized by pelvic floor disorders seem to seek care earlier.
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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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14
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Hunt CW, Cavallaro PM, Bordeianou LG. Metrics Used to Quantify Fecal Incontinence and Constipation. Clin Colon Rectal Surg 2021; 34:5-14. [PMID: 33536844 PMCID: PMC7843947 DOI: 10.1055/s-0040-1714245] [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] [Indexed: 12/14/2022]
Abstract
While fecal incontinence and constipation can be measured through physiological testing, the subjective experience of severity and impact on health-related quality of life lead to both being most effectively captured through patient-reported measures. Patient-reported measures of severity and impact help to determine baseline symptoms, guide clinical decision making, and compare various treatments. Here, we take pause to review the psychometric qualities that make effective instruments, and discuss some of the most commonly used instruments along with the reasons behind their use. In addition, we highlight the benefits of a standardized instrument designed to evaluate the major symptoms of patients presenting with pelvic floor disorders (including fecal incontinence and constipation). Ultimately, we aim to provide guidance in choosing appropriate instruments for clinical and research use.
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Affiliation(s)
- Cameron W. Hunt
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Paul M. Cavallaro
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Liliana G. Bordeianou
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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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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D'Amico F, Wexner SD, Vaizey CJ, Gouynou C, Danese S, Peyrin-Biroulet L. Tools for fecal incontinence assessment: lessons for inflammatory bowel disease trials based on a systematic review. United European Gastroenterol J 2020; 8:886-922. [PMID: 32677555 DOI: 10.1177/2050640620943699] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Fecal incontinence is a disabling condition affecting up to 20% of women. OBJECTIVE We investigated fecal incontinence assessment in both inflammatory bowel disease and non-inflammatory bowel disease patients to propose a diagnostic approach for inflammatory bowel disease trials. METHODS We searched on Pubmed, Embase and Cochrane Library for all studies on adult inflammatory bowel disease and non-inflammatory bowel disease patients reporting data on fecal incontinence assessment from January 2009 to December 2019. RESULTS In total, 328 studies were included; 306 studies enrolled non-inflammatory bowel disease patients and 22 studies enrolled inflammatory bowel disease patients. In non-inflammatory bowel disease trials the most used tools were the Wexner score, fecal incontinence quality of life questionnaire, Vaizey score and fecal incontinence severity index (in 187, 91, 62 and 33 studies). Anal manometry was adopted in 41.2% and endoanal ultrasonography in 34.0% of the studies. In 142 studies (46.4%) fecal incontinence evaluation was performed with a single instrument, while in 64 (20.9%) and 100 (32.7%) studies two or more instruments were used. In inflammatory bowel disease studies the Wexner score, Vaizey score and inflammatory bowel disease quality of life questionnaire were the most commonly adopted tools (in five (22.7%), five (22.7%) and four (18.2%) studies). Anal manometry and endoanal ultrasonography were performed in 45.4% and 18.2% of the studies. CONCLUSION Based on prior validation and experience, we propose to use the Wexner score as the first step for fecal incontinence assessment in inflammatory bowel disease trials. Anal manometry and/or endoanal ultrasonography should be taken into account in the case of positive questionnaires.
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Affiliation(s)
- Ferdinando D'Amico
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston USA
| | | | - Célia Gouynou
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Silvio Danese
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
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Brown HW, Braun EJ, Wise ME, Myers S, Li Z, Sampene E, Jansen SM, Moberg DP, Mahoney JE, Rogers RG. Small-Group, Community-Member Intervention for Urinary and Bowel Incontinence: A Randomized Controlled Trial. Obstet Gynecol 2020; 134:600-610. [PMID: 31403596 DOI: 10.1097/aog.0000000000003422] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To evaluate the effects of Mind Over Matter: Healthy Bowels, Healthy Bladder, a small-group intervention, on urinary and bowel incontinence symptoms among older women with incontinence. METHODS In this individually randomized group treatment trial, women aged 50 years and older with urinary, bowel incontinence, or both, were randomly allocated at baseline to participate in Mind Over Matter: Healthy Bowels, Healthy Bladder immediately (treatment group) or after final data collection (waitlist control group). The primary outcome was urinary incontinence (UI) improvement on the Patient Global Impression of Improvement at 4 months. Validated instruments assessed incontinence, self-efficacy, depression, and barriers to care-seeking. Intent-to-treat analyses compared differences between groups. Target sample size, based on an anticipated improvement rate of 45% in treated women vs 11% in the control group, 90% power, type I error of 0.05, with anticipated attrition of 25%, was 110. RESULTS Among 121 women randomized (62 treatment group; 59 control group), 116 (95%) completed the 4-month assessment. Most participants were non-Hispanic white (97%), with a mean age of 75 years (SD 9.2, range 51-98); 66% had attended some college. There were no significant between-group differences at baseline. At 4 months, 71% of treated women vs 23% of women in the control group reported improved UI on Patient Global Impression of Improvement (P<.001); 39% vs 5% were much improved (P<.001). Regarding bowel incontinence, 55% of treated women vs 27% of women in the control group improved on Patient Global Impression of Improvement (P<.005), with 35% vs 11% reporting much improvement (P<.005). Treated women improved significantly more than women in the control group on all validated instruments of incontinence severity, quality of life, and self-efficacy. Care-seeking rates were similar between groups. CONCLUSION Participation in a small-group intervention improves symptoms of both urinary and bowel incontinence in older women. Mind Over Matter is a feasible model with potential to bring effective behavioral solutions to the community. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT03140852.
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Affiliation(s)
- Heidi W Brown
- Departments of Obstetrics and Gynecology, Urology, Biostatistics, Population Health Sciences, and Medicine, University of Wisconsin-Madison School of Medicine and Public Health, the University of Wisconsin-Madison School of Pharmacy, Sonderegger Research Center, and the Wisconsin Institute for Healthy Aging, Community-Academic Aging Research Network, Madison, and the Medical College of Wisconsin, Milwaukee, Wisconsin; and the Department of Women's Health, Dell Medical School, the University of Texas at Austin, Austin, Texas
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Measuring Pelvic Floor Disorder Symptoms Using Patient-Reported Instruments: Proceedings of the Consensus Meeting of the Pelvic Floor Consortium of the American Society of Colon and Rectal Surgeons, the International Continence Society, the American Urogynecologic Society, and the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction. Dis Colon Rectum 2020; 63:6-23. [PMID: 31804265 DOI: 10.1097/dcr.0000000000001529] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Measuring Pelvic Floor Disorder Symptoms Using Patient-Reported Instruments: Proceedings of the Consensus Meeting of the Pelvic Floor Consortium of the American Society of Colon and Rectal Surgeons, the International Continence Society, the American Urogynecologic Society, and the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction. Female Pelvic Med Reconstr Surg 2019; 26:1-15. [PMID: 31833996 DOI: 10.1097/spv.0000000000000817] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Bordeianou LG, Anger J, Boutros M, Birnbaum E, Carmichael JC, Connell K, De EJB, Mellgren A, Staller K, Vogler SA, Weinstein MM, Yafi FA, Hull T. Measuring pelvic floor disorder symptoms using patient-reported instruments: proceedings of the consensus meeting of the pelvic floor consortium of the American Society of Colon and Rectal Surgeons, the International Continence Society, the American Urogynecologic Society, and the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction. Tech Coloproctol 2019; 24:5-22. [DOI: 10.1007/s10151-019-02125-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 11/20/2019] [Indexed: 12/17/2022]
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21
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Sphincter repair or Sacral Nerve Modulation: Still debatable? SEMINARS IN COLON AND RECTAL SURGERY 2019. [DOI: 10.1016/j.scrs.2019.100708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Buono K, Davé-Heliker B. Mechanical inserts for the treatment of faecal incontinence: A systematic review. Arab J Urol 2019; 17:69-76. [PMID: 31258946 PMCID: PMC6583709 DOI: 10.1080/2090598x.2019.1589776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2018] [Indexed: 11/04/2022] Open
Abstract
Objective: To perform a systematic review of the literature to examine original research on the role of mechanical inserts, both vaginal and anal, for the treatment of faecal incontinence (FI). Materials and methods: We searched the PubMed, Cochrane Library, and ClinicalTrials.gov databases for any peer-reviewed original research in English on the role of mechanical inserts for the treatment of FI. Results: We identified 35 unique citations. After title review and exclusion of articles not reporting original research, eight publications were included in the final review: two focused on vaginal inserts and six focused on anal inserts. Limited evidence indicates that both vaginal and anal inserts can be an effective and safe therapeutic option for patients with FI. Conclusions: Data regarding vaginal and anal mechanical inserts for the treatment of FI, albeit limited, suggest that inserts can be included in a discussion of therapeutic options for a patient with FI. Further studies are needed to elucidate long-term usability, efficacy, and safety. Abbreviations: FI: faecal incontinence; (m)ITT: (modified) intention-to-treat
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Affiliation(s)
- Kristen Buono
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University of California Irvine, Orange, CA, USA
| | - Bhumy Davé-Heliker
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University of California Irvine, Orange, CA, USA
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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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Moskowitz D, Adelstein SA, Lucioni A, Kobashi KC, Lee UJ. Practice patterns in the diagnosis and treatment of fecal incontinence with sacral neuromodulation: Can urologists impact this gap in care? Turk J Urol 2019; 45:37-41. [PMID: 30668308 DOI: 10.5152/tud.2018.94041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 10/12/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The prevalence of fecal incontinence (FI) is 8% in the United States. Many patients will not seek treatment and the condition is underdiagnosed. Sacral neuromodulation (SNM) is effective in treating FI, and so urologists can play a key role in its treatment. We examine the practice patterns and treatment of FI with SNM in our institution. MATERIAL AND METHODS The electronic medical record was queried for the proportion of patients seen for FI in the institution, the urology department, and among the female pelvic medicine and reconstructive surgery (FPMRS) urologists. The patients who underwent SNM for FI were evaluated for progression to second stage procedure. RESULTS The proportion of patients seen for FI is 0.96% in the institution as a whole, 7.9% in the urology department, and 17.9% among FPMRS urologists. Fourteen patients underwent first stage SNM for FI or dual urinary/fecal incontinence, and they all progressed to a second stage procedure. Thirteen of these were performed by FPMRS urologists. CONCLUSION In our institution, the proportion of patients seen for FI was lower than the prevalence of this condition. Because patients with urinary incontinence are more likely to have FI, urologists are in a unique position to identify these patients and offer treatment that can improve their quality of life. We acknowledge a gap in care of the patients with FI and an opportunity for urologists to help patients with this devastating yet treatable condition.
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Affiliation(s)
- Dena Moskowitz
- Department of Urology, University of California Irvine, Orange, CA, USA
| | - Sarah A Adelstein
- Department of Urology, Rush University Medical Center, Chicago, IL, USA
| | - Alvaro Lucioni
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, WA, USA
| | - Kathleen C Kobashi
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, WA, USA
| | - Una J Lee
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, WA, USA
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A systematic review of non-invasive modalities used to identify women with anal incontinence symptoms after childbirth. Int Urogynecol J 2018; 30:869-879. [DOI: 10.1007/s00192-018-3819-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 11/08/2018] [Indexed: 12/18/2022]
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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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Brown HW, Wise ME, Westenberg D, Schmuhl NB, Brezoczky KL, Rogers RG, Constantine ML. Validation of an instrument to assess barriers to care-seeking for accidental bowel leakage in women: the BCABL questionnaire. Int Urogynecol J 2017; 28:1319-1328. [PMID: 28236039 DOI: 10.1007/s00192-016-3261-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 12/30/2016] [Indexed: 12/14/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Fewer than 30% of women with accidental bowel leakage (ABL) seek care, despite the existence of effective, minimally invasive therapies. We developed and validated a condition-specific instrument to assess barriers to care-seeking for ABL in women. METHODS Adult women with ABL completed an electronic survey about condition severity, patient activation, previous care-seeking, and demographics. The Barriers to Care-seeking for Accidental Bowel Leakage (BCABL) instrument contained 42 potential items completed at baseline and again 2 weeks later. Paired t tests evaluated test-retest reliability. Factor analysis evaluated factor structure and guided item retention. Cronbach's alpha evaluated internal consistency. Within and across factor item means generated a summary BCABL score used to evaluate scale validity with six external criterion measures. RESULTS Among 1,677 click-throughs, 736 (44%) entered the survey; 95% of eligible female respondents (427 out of 458) provided complete data. Fifty-three percent of respondents had previously sought care for their ABL; median age was 62 years (range 27-89); mean Vaizey score was 12.8 (SD = 5.0), indicating moderate to severe ABL. Test-retest reliability was excellent for all items. Factor extraction via oblique rotation resulted in the final structure of 16 items in six domains, within which internal consistency was high. All six external criterion measures correlated significantly with BCABL score. CONCLUSIONS The BCABL questionnaire, with 16 items mapping to six domains, has excellent criterion validity and test-retest reliability when administered electronically in women with ABL. The BCABL can be used to identify care-seeking barriers for ABL in different populations, inform targeted interventions, and measure their effectiveness.
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Affiliation(s)
- Heidi Wendell Brown
- Department of OB/GYN, University of Wisconsin-Madison School of Medicine and Public Health, 600 Highland Avenue, Box 6188, Madison, WI, 53792, USA.
| | - Meg E Wise
- Sonderegger Research Center, University of Wisconsin-Madison School of Pharmacy, Madison, WI, USA
| | - Danielle Westenberg
- Department of OB/GYN, University of Wisconsin-Madison School of Medicine and Public Health, 600 Highland Avenue, Box 6188, Madison, WI, 53792, USA
| | - Nicholas B Schmuhl
- Department of OB/GYN, University of Wisconsin-Madison School of Medicine and Public Health, 600 Highland Avenue, Box 6188, Madison, WI, 53792, USA
| | | | - Rebecca G Rogers
- Dell Medical School at The University of Texas at Austin, Austin, TX, USA
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Brown HW, Rogers RG, Wise ME. Barriers to seeking care for accidental bowel leakage: a qualitative study. Int Urogynecol J 2016; 28:543-551. [PMID: 27844123 DOI: 10.1007/s00192-016-3195-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 10/23/2016] [Indexed: 12/17/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Fewer than 50 % of women with urinary incontinence (UI) and 30 % of women with accidental bowel leakage (ABL) seek care. We sought to describe barriers to care seeking for ABL to inform development of an instrument to measure these barriers. METHODS We recruited women with ABL with varied prior care-seeking experiences to participate in focus groups and cognitive interviews so we could understand factors that may have prevented or delayed care seeking. Focus groups continued until thematic saturation was reached using conventional content analysis. Final themes were established and characterized by comparing within and across the focus groups and with previously described UI and ABL care-seeking barriers. Cognitive interviews were confirmatory. RESULTS Thirty-nine women (aged 46-85) participated in six focus groups and ten cognitive interviews; 89 % were white, 8 % African American, and 3 % Latina. We identified 12 barriers to seeking care for ABL: (1) Lack of knowledge about the condition; (2) Lack of knowledge about treatment; (3) Fear of testing/treatment; (4) Normative thinking; (5) Avoidance/denial; (6) Life impact; (7) Embarrassment/shame; (8) Self-blame; (9) Stigma; (10) Isolation; (11) Provider barriers; (12) Access limitations. These 12 barriers encompassed three overarching themes: the internalized self in relation to ABL; perceptions about ABL and its treatments; and interaction with the healthcare system. CONCLUSIONS ABL care-seeking barriers are similar to those described for UI, with the notable addition of lack of knowledge that ABL is a medical condition experienced by others. Interventions to promote access to effective treatments for ABL should include information about prevalence and treatability.
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Affiliation(s)
- Heidi Wendell Brown
- Wisconsin Multidisciplinary K12 Urologic Research Career Development Program Scholar, University of Wisconsin-Madison School of Medicine and Public Health, 600 Highland Avenue, Box 6188, Madison, WI, 53792, USA.
| | - Rebecca G Rogers
- University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Meg E Wise
- University of Wisconsin-Madison School of Pharmacy, Madison, WI, USA
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Hallock JL, Handa VL. The Epidemiology of Pelvic Floor Disorders and Childbirth: An Update. Obstet Gynecol Clin North Am 2016; 43:1-13. [PMID: 26880504 DOI: 10.1016/j.ogc.2015.10.008] [Citation(s) in RCA: 111] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Using a lifespan model, this article presents new scientific findings regarding risk factors for pelvic floor disorders (PFDs), focusing on the role of childbirth in the development of single or multiple coexisting PFDs. Phase I of the model includes predisposing factors, such as genetic predisposition and race. Phase II includes inciting factors, such as obstetric events. Prolapse, urinary incontinence (UI), and fecal incontinence (FI) are more common among vaginally parous women, although the impact of vaginal delivery on risk of FI is less dramatic than prolapse and UI. Phase III includes intervening factors, such as age and obesity.
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Affiliation(s)
- Jennifer L Hallock
- Female Pelvic Medicine & Reconstructive Surgery, Johns Hopkins School of Medicine, 4940 Eastern Avenue, 301 Building, Suite 3200, Baltimore, MD 21224, USA
| | - Victoria L Handa
- Gynecology & Obstetrics, Johns Hopkins School of Medicine, 4940 Eastern Avenue, 301 Building, Suite 3200, Baltimore, MD 21224, USA.
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Abstract
Fecal incontinence is a devastating condition, vastly under-reported, and may affect up to 18% of the population. While conservative management may be efficacious in a large portion of patients, those who are refractory will likely benefit from appropriate surgical intervention. There are a wide variety of surgical approaches to fecal incontinence management, and knowledge and experience are crucial to choosing the appropriate procedure and maximizing functional outcome while minimizing risk. In this article, we provide a comprehensive description of surgical options for fecal incontinence to help the clinician identify an appropriate intervention.
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Affiliation(s)
- Steven D Wexner
- a 1 Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL 33331, USA
| | - Joshua Bleier
- b 2 University of Pennsylvania Health System, Department of Surgery, 800 Walnut St. 20th Floor, Philadelphia, PA 19106, USA
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Abstract
Fecal incontinence (FI) is a chronic and debilitating condition that carries a significant health, economic, and social burden. FI has a considerable psychosocial and financial impact on patients and their families. A variety of treatment modalities are available for FI including behavioral and dietary modifications, pharmacotherapy, pelvic floor physical therapy, bulking agents, anal sphincteroplasty, sacral nerve stimulation, artificial sphincters, magnetic sphincters, posterior anal sling, and colostomy.
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Affiliation(s)
- Katarzyna Bochenska
- Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Anne-Marie Boller
- Division of Gastrointestinal Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Abstract
Pelvic floor dysfunction and fecal incontinence is a common and debilitating condition in women, particularly as women age, and often goes under-reported to health care providers. It is important for providers to ask patients about possible symptoms. An algorithm for evaluation and treatment is presented. Current and future therapies are described and discussed.
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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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Brown H, Grimes C. Current Trends in Management of Defecatory Dysfunction, Posterior Compartment Prolapse, and Fecal Incontinence. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2016; 5:165-171. [PMID: 27547494 DOI: 10.1007/s13669-016-0148-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
While it would be our hope to report that there have been significant gains in the understanding of the correlation between the posterior vaginal compartment and defecatory dysfunction in the last year, this is not the case. Instead, we review the highlights of management of posterior vaginal compartment and defecatory dysfunction including 1) defining and understanding the patient's symptoms; 2) considering systemic disorders, motility dysfunction, and mechanical causes that may be contributing; 3) encouraging conservative management as first-line therapy; and 4) recognizing which surgical options are likely to improve specific symptoms. This is then followed by an update on treatment options for fecal incontinence, which we now prefer to refer to as accidental bowel leakage. We are able to report on five exciting and innovative treatment approaches for accidental bowel leakage. As the scientific community increases focus on patient-centered outcomes, we are likely on the verge of having a greater understanding of how treatment options for posterior compartment prolapse and defecatory dysfunction can improve patient symptoms. This year, we can report that strong evidence based recommendations simply do not exist, and this area is ripe for future investigation.
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Affiliation(s)
- Heidi Brown
- University of Wisconsin-Madison School of Medicine & Public Health, Departments of Obstetrics & Gynecology and Urology, Female Pelvic Medicine & Reconstructive Surgery Section, 600 Highland Avenue, Box 6188 (H4/656), Madison, WI 53792, , Fax:
| | - Cara Grimes
- Columbia University Medical Cnter, Department of Obstetrics and Gynecology, Section of Female Pelvic Medicine and Reconstructive Surgery, 622 West 168 Street, PH 16, Room 127, New York, NY 10032, Phone:212-305-0189
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Ratto C, Donisi L, Litta F, Campennì P, Parello A. Implantation of SphinKeeper(TM): a new artificial anal sphincter. Tech Coloproctol 2015; 20:59-66. [PMID: 26658726 PMCID: PMC4751162 DOI: 10.1007/s10151-015-1396-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 10/30/2015] [Indexed: 12/17/2022]
Abstract
Introduction A new artificial anal sphincter, SphinKeeperTM, was devised with the aim to treat fecal incontinence (FI) by implanting specifically designed self-expandable prostheses into the intersphincteric space. Preliminary data concerning the procedure feasibility and prosthesis localization at 3 months are presented. Methods SphinKeeperTM prostheses in the native state are dehydrated, thin, solid cylinder (length 29 mm, diameter 3 mm), changing their state (shorter—length 23 mm, thicker—diameter 7 mm—and softer, with shape memory) within 48 h of contact with fluids. In this study, 10 prostheses were implanted in each patient with FI under local anesthesia and under endoanal ultrasound (EAUS) guidance, into the upper-middle intersphincteric space of the anal canal by a specifically designed delivery system. EAUS was used postoperatively to assess prostheses dislocation. Results Ten patients (5 females; median age 58 years, range 20–75) were enrolled and treated with SphinKeeperTM implantation. Median duration of procedure (performed by endoanal ultrasound guidance) was 40 min (range 30–45). Neither intraoperative nor postoperative complications were reported after a 3-month follow-up. In one patient, a partial dislocation of a single prosthesis was documented by EAUS, causing anal discomfort which resolved after 1 week. Conclusion SphinKeeperTM can be safely implanted in patients with FI of different etiology. Implantation was well tolerated with no dislodgment of implants at 3-month follow-up.
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Affiliation(s)
- C Ratto
- Proctology Unit, Department of Surgical Sciences, Catholic University, Largo A. Gemelli, 8, 00168, Rome, Italy.
| | - L Donisi
- Proctology Unit, Department of Surgical Sciences, Catholic University, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - F Litta
- Proctology Unit, Department of Surgical Sciences, Catholic University, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - P Campennì
- Proctology Unit, Department of Surgical Sciences, Catholic University, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - A Parello
- Proctology Unit, Department of Surgical Sciences, Catholic University, Largo A. Gemelli, 8, 00168, Rome, Italy
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Montroni I, Wexner SD. Reoperative surgery for fecal incontinence. SEMINARS IN COLON AND RECTAL SURGERY 2015. [DOI: 10.1053/j.scrs.2015.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
OBJECTIVE To evaluate the effectiveness and safety of a vaginal bowel-control device and pump system for fecal incontinence treatment. METHODS Women with a minimum of four fecal incontinence episodes over 2 weeks were fit with the intravaginal device. Treatment success, defined as a 50% or greater reduction of incontinent episodes, was assessed at 1 month. Participants were invited into an optional extended-wear period of another 2 months. Secondary outcomes included symptom improvement measured by the Fecal Incontinence Quality of Life, Modified Manchester Health Questionnaire, and Patient Global Impression of Improvement. Adverse events were collected. Intention-to-treat analysis included participants who were successfully fit entering treatment. Per protocol, analysis included participants with a valid 1-month treatment diary. RESULTS Sixty-one of 110 (55.5%) participants from six clinical sites were successfully fit and entered treatment. At 1 month, intention-to-treat success was 78.7% (48/61, P<.001); per protocol success, 85.7% (48/56, P<.001) and 85.7% (48/56) considered bowel symptoms "very much better" or "much better." There was significant improvement in all Fecal Incontinence Quality of Life (P<.001) and Modified Manchester (P≤.007) subscales. Success rate at 3 months was 86.4% (38/44; 95% confidence interval 73-95%). There were no serious adverse events; the most common study-wide device-related adverse event was pelvic cramping or discomfort (25/110 participants [22.7%]), the majority of events (16/25 [64%]) occurring during the fitting period. CONCLUSION In women successfully fit with a vaginal bowel-control device for nonsurgical treatment for fecal incontinence, there was significant improvement in fecal incontinence by objective and subjective measures. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, www.clinicaltrials.gov, NCT01655498. LEVEL OF EVIDENCE : II.
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Herman RM, Berho M, Murawski M, Nowakowski M, Ryś J, Schwarz T, Wojtysiak D, Wexner SD. Defining the histopathological changes induced by nonablative radiofrequency treatment of faecal incontinence--a blinded assessment in an animal model. Colorectal Dis 2015; 17:433-40. [PMID: 25524045 DOI: 10.1111/codi.12874] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 10/02/2014] [Indexed: 01/04/2023]
Abstract
AIM Nonablative radiofrequency (RF) sphincter remodelling has been used to treat gastro-oesophageal reflux disease (GERD) and faecal incontinence (FI). Its mechanism of action is unclear. We aimed to investigate the histomorphological and pathophysiological changes to the internal and external anal sphincter (IAS and EAS) following RF remodelling. METHOD An experimental FI model was created in 12 female pigs: eight underwent RF 6 weeks following induction of FI (FI+RF) and four were untreated (UFI). Four animals served as controls (CG). Two blinded pathologists examined all haematoxylin and eosin and trichrome stained slides. RESULTS Compared with the UFI group, histological examination of the IAS in the FI+RF group demonstrated an increased smooth muscle (SM)/connective tissue ratio (77.2 vs 68.1%, P < 0.05) and increased collagen I compared with collagen III content (67.2 vs 54.9%, P < 0.001). The RF+FI group exhibited greater SM bundle thickness compared with the UFI group (SM width 486.93 vs 338.59 μm, P < 0.01; height 4384.4 vs 3321.0 μm, P < 0.05). The EAS of the FI+RF animals showed a significantly higher type I/II fibre ratio (33.5 vs 25.2%, P = 0.023) and fibre type I diameter (67.2 vs 59.7 μm, P < 0.001) compared with the UFI group. Post-RF manometry showed higher basal (18.8 vs 0 mmHg, P < 0.001) and squeeze (76.8 vs 12.4 mmHg, P < 0.05) anal pressures. After RF treatment, the number of interstitial cells of Cajal was significantly reduced compared with the UFI and CG groups [0.9 (FI+RF) vs 6.7 (UFI) vs 0.7 (CG) per mm(2) , P < 0.001]. CONCLUSION In an animal model nonablative RF appeared to induce morphological changes in the IAS and EAS leading to an anatomical state reminiscent of normal sphincter structure.
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Affiliation(s)
- R M Herman
- Jagiellonian University Medical College, Krakow, Poland
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Steele SR, Varma MG, Prichard D, Bharucha AE, Vogler SA, Erdogan A, Rao SSC, Lowry AC, Lange EO, Hall GM, Bleier JIS, Senagore AJ, Maykel J, Chan SY, Paquette IM, Audett MC, Bastawrous A, Umamaheswaran P, Fleshman JW, Caton G, O'Brien BS, Nelson JM, Steiner A, Garely A, Noor N, Desrosiers L, Kelley R, Jacobson NS. The evolution of evaluation and management of urinary or fecal incontinence and pelvic organ prolapse. Curr Probl Surg 2015; 52:17-75. [PMID: 25919203 DOI: 10.1067/j.cpsurg.2015.01.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 01/29/2015] [Indexed: 12/13/2022]
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Johnson BL, Abodeely A, Ferguson MA, Davis BR, Rafferty JF, Paquette IM. Is sacral neuromodulation here to stay? Clinical outcomes of a new treatment for fecal incontinence. J Gastrointest Surg 2015; 19:15-9; discussion 19-20. [PMID: 25115325 DOI: 10.1007/s11605-014-2611-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 07/22/2014] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Sacral neuromodulation (SNM) was approved by the FDA for the treatment of fecal incontinence (FI) in 2011, and previous industry-sponsored trials have shown excellent clinical outcomes. The purpose of this study is to examine clinical outcomes of patients treated during our initial experience with SNM. METHODS A prospective database of patients treated with SNM for FI by one of three colorectal surgeons at two separate institutions was maintained starting in 2011. Patients showing ≥50% improvement of weekly incontinent episodes during test stimulation were offered permanent implantation of the SNM device. Disease severity was tracked using the Wexner score. RESULTS A total of 145 patients received a full system implantation (of 152 who received test stimulation). The median preoperative Wexner score of 14 decreased to 3, 3 months after implantation and persisted to 12 months. At 12 months, 95.2% of patients achieved >50% improvement in Wexner Score and 67.6% achieved >75% improvement. The most common adverse event was infection (3.4%). Three patients (2.1%) required lead revision. CONCLUSIONS SNM is a safe and effective therapy for the treatment of FI. Postoperative patient surveillance is important, as many patients require programming changes, and some will require a lead revision over time.
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Affiliation(s)
- Bobby L Johnson
- Department of Surgery, Division of Colorectal Surgery, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
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Bharucha AE, Dunivan G, Goode PS, Lukacz ES, Markland AD, Matthews CA, Mott L, Rogers RG, Zinsmeister AR, Whitehead WE, Rao SSC, Hamilton FA. Epidemiology, pathophysiology, and classification of fecal incontinence: state of the science summary for the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) workshop. Am J Gastroenterol 2015; 110:127-36. [PMID: 25533002 PMCID: PMC4418464 DOI: 10.1038/ajg.2014.396] [Citation(s) in RCA: 175] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 11/01/2014] [Indexed: 12/11/2022]
Abstract
In August 2013, the National Institutes of Health sponsored a conference to address major gaps in our understanding of the epidemiology, pathophysiology, and management of fecal incontinence (FI) and to identify topics for future clinical research. This article is the first of a two-part summary of those proceedings. FI is a common symptom, with a prevalence that ranges from 7 to 15% in community-dwelling men and women, but it is often underreported, as providers seldom screen for FI and patients do not volunteer the symptom, even though the symptoms can have a devastating impact on the quality of life. Rough estimates suggest that FI is associated with a substantial economic burden, particularly in patients who require surgical therapy. Bowel disturbances, particularly diarrhea, the symptom of rectal urgency, and burden of chronic illness are the strongest independent risk factors for FI in the community. Smoking, obesity, and inappropriate cholecystectomy are emerging, potentially modifiable risk factors. Other risk factors for FI include advanced age, female gender, disease burden (comorbidity count, diabetes), anal sphincter trauma (obstetrical injury, prior surgery), and decreased physical activity. Neurological disorders, inflammatory bowel disease, and pelvic floor anatomical disturbances (rectal prolapse) are also associated with FI. The pathophysiological mechanisms responsible for FI include diarrhea, anal and pelvic floor weakness, reduced rectal compliance, and reduced or increased rectal sensation; many patients have multifaceted anorectal dysfunctions. The type (urge, passive or combined), etiology (anorectal disturbance, bowel symptoms, or both), and severity of FI provide the basis for classifying FI; these domains can be integrated to comprehensively characterize the symptom. Several validated scales for classifying symptom severity and its impact on the quality of life are available. Symptom severity scales should incorporate the frequency, volume, consistency, and nature (urge or passive) of stool leakage. Despite the basic understanding of FI, there are still major knowledge gaps in disease epidemiology and pathogenesis, necessitating future clinical research in FI.
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Affiliation(s)
- Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Gena Dunivan
- Department of Obstetrics and Gynecology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Patricia S Goode
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Emily S Lukacz
- Department of Reproductive Medicine, UC San Diego Health Systems, La Jolla, California, USA
| | - Alayne D Markland
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Catherine A Matthews
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Louise Mott
- Simon Foundation, Langley, British Columbia, Canada
| | - Rebecca G Rogers
- Department of Obstetrics and Gynecology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Alan R Zinsmeister
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - William E Whitehead
- 1] Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina, USA [2] Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Satish S C Rao
- Department of Gastroenterology, Georgia Regents University, Augusta, Georgia, USA
| | - Frank A Hamilton
- National Institutes of Diabetes, Digestive and Kidney Diseases, National Institute of Health, Bethesda, Maryland, USA
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Parker-Autry CY, Gleason JL, Griffin RL, Markland AD, Richter HE. Vitamin D deficiency is associated with increased fecal incontinence symptoms. Int Urogynecol J 2014; 25:1483-9. [PMID: 24807423 PMCID: PMC4192075 DOI: 10.1007/s00192-014-2389-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 03/30/2014] [Indexed: 10/25/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Vitamin D is an important micronutrient in muscle function. We hypothesize that vitamin D deficiency may contribute to fecal incontinence (FI) symptoms by affecting the anal continence mechanism. Our goal was to characterize the association of vitamin D deficiency as a variable affecting FI symptoms and its impact on health-related quality of life (HR-QoL). METHODS This case-control study assessed women seen at a tertiary-care referral center. Participants were identified as having had a serum vitamin D level obtained within a year of their visit: cases were women presenting for care for FI symptoms; controls were women without any pelvic floor symptoms presenting to the same clinical site for general gynecologic care. Cases completed the Modified Manchester Health Questionnaire (MMHQ) and the Fecal Incontinence Severity Index to measure symptom severity and burden on QoL. RESULTS Among the 31 cases and 81 controls, no demographic or medical differences existed. Women with FI had lower vitamin D levels (mean 29.2 ± 12.3 cases vs. 35 ± 14.1 ng/ml controls p = 0.04). The odds of vitamin D deficiency were higher in women with FI compared with controls [odds ratio (OR) 2.77, 95 % confidence interval (CI) 1.08-7.09]. Among cases, women with vitamin D deficiency (35 %) had higher MMHQ scores, indicating greater FI symptom burden [51.3 ± 29.3 (vitamin D deficient) vs. 30 ± 19.5 (vitamin D sufficiency), p = 0.02]. No differences were noted for FI severity, p = 0.07. CONCLUSIONS Vitamin D deficiency is prevalent in women with fecal incontinence and may contribute to patient symptom burden.
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Affiliation(s)
- Candace Y Parker-Autry
- Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, Wake Forest University School of Medicine, Winston-Salem, NC, USA,
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Matthews CA. Risk factors for urinary, fecal, or double incontinence in women. Curr Opin Obstet Gynecol 2014; 26:393-7. [DOI: 10.1097/gco.0000000000000094] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Quantifying patient improvement following sacral neuromodulation: is it time for a new scoring system for fecal incontinence? Dis Colon Rectum 2014; 57:1209-12. [PMID: 25203378 DOI: 10.1097/dcr.0000000000000199] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The Cleveland Clinic Florida Fecal Incontinence score is widely used to assess the severity of fecal incontinence. OBJECTIVE We hypothesized that the Cleveland Clinic Fecal Florida Incontinence score is useful at establishing baseline disease severity, but it may underestimate the response to treatment following sacral neuromodulation because of the large number of patients who still wear a pad despite improved continence, as well as the inability to track improvements in urgency. DATA SOURCES Data were obtained from prospectively maintained database of patients treated with sacral neuromodulation for fecal incontinence at 2 institutions beginning in 2011. DESIGN A retrospective review of the individual components of Cleveland Clinic Fecal Florida Incontinence scores in response to treatment with sacral neuromodulation was performed. SETTINGS The study was conducted at 1 academic medical center and 1 community medical center. PATIENTS One hundred twenty-one consecutive patients were treated with sacral neuromodulation for fecal incontinence. INTERVENTIONS No interventions occurred. MAIN OUTCOME MEASURES Individual components of posttreatment Cleveland Clinic Florida Fecal Incontinence scores and subjective improvement in fecal urgency were the primary outcomes measured. RESULTS The median preoperative Cleveland Clinic Fecal Florida Incontinence score of 14 decreased to 3 (interquartile range, 2-4) at 12 months. Of the patients, 66.1% reported still wearing a pad after the procedure. The reason for wearing a pad was residual fecal incontinence (41%), habit despite normal continence (35.3%), and urinary incontinence with complete fecal continence (23.5%). Of patients who report wearing a pad, 59% have falsely elevated Cleveland Clinic Fecal Florida Incontinence scores owing to wearing a pad despite complete fecal continence. Additionally, 96.3% of patients reported improvement in fecal urgency. LIMITATIONS This retrospective study did not include a comparison with an alternative scoring system. CONCLUSIONS Although the Cleveland Clinic Fecal Florida Incontinence score is a validated scale, which is simple to use for baseline disease severity, it may underestimate patient response to treatment. Additionally, it does not capture improvement in urgency. The ideal scoring system would be easy to use in clinical practice, and would account for improvement in fecal urgency.
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Lehto K, Ylönen K, Hyöty M, Collin P, Huhtala H, Aitola P. Anal incontinence: long-term alterations in the incidence and healthcare usage. Scand J Gastroenterol 2014; 49:790-3. [PMID: 24873896 DOI: 10.3109/00365521.2014.915053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The aim of the study was to determine the alterations in the occurrence of incontinence and how subjects suffering from incontinence seek and receive healthcare services over a 10-year follow-up period. METHODS Postal questionnaires (Wexner Incontinence Score, Fecal Incontinence Quality of Life Scale, a questionnaire to investigate the management of fecal incontinence and the frequency of urinary incontinence) were sent to subjects who had reported anal incontinence in our population-based study in 2003. For each incontinent person (n = 155) from the 2003 series, we identified two control subjects (n = 310) who did not suffer from incontinence. RESULTS Of the initially incontinent, 47 (58%) had remained incontinent after a follow up of 10 years. Almost 80% of the incontinent subjects in 2012 were female. Of the 152 initially continent, 12 (7.9%) had developed symptoms, all of whom were females. Urinary incontinence was present in approximately 60% of incontinent subjects. The majority (57.8%) of the subjects still incontinent in 2012 felt that they needed help for the complaint, but only 30.9% had received any, and only 7.4% received any benefit. The most common treatment was medication. The subjective incontinence impaired the quality of life. CONCLUSION Incontinence is a chronic long-lasting disorder. The current management of anal incontinence is not satisfactory. The primary healthcare system should be more aware of the nature of this condition to find and offer treatment for the patients.
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Affiliation(s)
- Kirsi Lehto
- School of Medicine, University of Tampere , Tampere , Finland
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Cichowski SB, Dunivan GC, Rogers RG, Komesu YM. Patients' experience compared with physicians' recommendations for treating fecal incontinence: a qualitative approach. Int Urogynecol J 2014; 25:935-40. [PMID: 24573357 PMCID: PMC4562421 DOI: 10.1007/s00192-013-2322-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Accepted: 12/28/2013] [Indexed: 01/18/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Using qualitative methods, we compared physician-recommended treatment options for fecal incontinence to patient knowledge of treatment options. Our hypothesis was that physician recommendations were not being communicated well to patients and that this impaired patients' ability to cope with fecal incontinence. METHODS Cognitive interviews were conducted with physicians who routinely care for women with fecal incontinence. Physicians were asked to describe their typical nonsurgical treatment recommendations and counseling for fecal incontinence. Women with bothersome fecal incontinence were recruited to participate in focus groups and asked about personal experience with fecal incontinence symptoms and treatment options. For both physician interviews and patient focus groups, qualitative data analysis was performed using grounded-theory methodology. RESULTS Physicians identified several barriers patients face when seeking treatment: lack of physician interest toward fecal incontinence, and patient embarrassment in discussing fecal incontinence. Physicians universally recommended fiber and pelvic floor exercise; they felt the majority (approximately 70-80 %) of patients will improve with these therapies. Collectively, patients were able to identify all treatment recommendations given by physicians, although many had discovered these treatments through personal experience. Three concepts emerged regarding treatment options that physicians did not identify but that patients felt were important in their treatment: hope for improvement, personal effort to control symptoms, and encouragement to go on living life fully. CONCLUSIONS Whereas physicians had treatment to offer women with fecal incontinence, women had already found the best treatments through personal research and effort. Women want to hear a message of hope and encouragement and perceive personal effort from providers.
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Affiliation(s)
- Sara B Cichowski
- Fellow Female Pelvic Medicine & Reconstructive Surgery, 1 University of New Mexico, MSC 10-5580, Albuquerque, NM, 87131-0001, USA,
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Thiagamoorthy G, Johnson A, Thakar R, Sultan AH. National survey of perineal trauma and its subsequent management in the United Kingdom. Int Urogynecol J 2014; 25:1621-7. [DOI: 10.1007/s00192-014-2406-x] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 04/13/2014] [Indexed: 11/30/2022]
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