Accidental bowel leakage in the mature women's health study: prevalence and predictors

Correlation Between Mobile-Application Electronic Bowel Diary and Validated Questionnaires in Women with Fecal Incontinence

INTRODUCTION AND HYPOTHESIS

Despite growing interest in a mobile-app bowel diary to assess fecal incontinence (FI) symptoms, data are limited regarding the correlation between mobile-app diary and questionnaire-based outcomes. The primary aim is to determine whether percentage reduction in FI episodes (FIEs)/week recorded on a mobile-app diary correlates with changes in scores of validated FI-symptom measures from baseline to 12 weeks in women with FI undergoing percutaneous tibial nerve stimulation (PTNS) versus sham.

METHODS

This is a planned secondary analysis of a multicenter randomized trial in which women with FI underwent PTNS or sham. FIEs were collected using a mobile-app diary at baseline and after 12 weekly sessions. FI-symptom-validated measures included St. Mark's, Accidental Bowel Leakage Evaluation, FI Severity Index (FISI), Colorectal Anal Distress Inventory, Colorectal Anal Impact Questionnaire, FI Quality of Life, Patient Global Impression of Improvement (PGI-I), and Patient Global Symptom Control (PGSC) rating. Spearman's correlation coefficient (ρ) was computed between %-reduction in FIEs/week and change in questionnaire scores from baseline to 12 weeks. Significance was set at 0.005 to account for multiple comparisons.

RESULTS

Baseline characteristics of 163 women (109 PTNS, 54 sham) include mean age 63.4±11.6, 81% white, body mass index 29.4±6.6 kg/m2, 4% previous FI surgeries, 6.6±5.5 FIEs/week, and St. Mark's score 17.4±2.6. A significant correlation was demonstrated between %-reduction in FIEs/week and all questionnaires (p<0.005). A moderate-strength correlation (|ρ|>0.4) was observed for St. Mark's (ρ=0.48), FISI (ρ=0.46), PGI-I (ρ=0.51), and PGSC (ρ=-0.43).

CONCLUSIONS

In women with FI randomized to PTNS versus sham, a moderate correlation was noted between FIEs measured via mobile-app diary and FI-symptom-validated questionnaire scores.

Is percutaneous tibial nerve stimulation (PTNS) effective for fecal incontinence (FI) in adults compared with sham electrical stimulation? A meta-analysis

BACKGROUND

Sacral nerve neuromodulation (SNM) has been considered the optimal second-line treatment for fecal incontinence (FI). However, SNM involves high cost and requires highly skilled operators. Percutaneous tibial nerve stimulation (PTNS) has emerged as an alternative treatment modality for FI, yielding varying clinical outcomes. We conducted this meta-analysis to evaluate the effectiveness and safety of PTNS compared to sham electrical stimulation for FI.

METHODS

PubMed, Embase, Web of Science, and the Cochrane Library were searched for studies from May 12, 2012 to May 12, 2022.

RESULTS

Four randomized controlled studies were included in this review, involving a total of 439 adult patients with FI (300 in the PTNS group and 194 in the sham electrical stimulation group). Our meta-analysis revealed that PTNS demonstrated superior efficacy in reducing weekly episodes of FI compared to the control groups (MD - 1.6, 95% CI - 2.94 to - 0.26, p = 0.02, I2 = 30%). Furthermore, a greater proportion of patients in the PTNS group reported more than a 50% reduction in FI episodes per week (RR 0.73, 95% CI 0.57-0.94, p = 0.02, I2 = 6%). However, no significant differences were observed in any domains of the FI Quality of Life (QoL) and St Mark's incontinence scores (MD - 2.41, 95% CI - 5.1 to 0.27, p = 0.08, I2 = 67%). Importantly, no severe adverse events related to PTNS were reported in any of the participants.

CONCLUSIONS

Our meta-analysis revealed that PTNS was more effective than sham stimulation in reducing FI episodes and led to a higher proportion of patients reporting more than a 50% reduction in weekly FI episodes.

Optimizing the Utility of Anorectal Manometry for Diagnosis and Therapy: A Roundtable Review and Recommendations

BACKGROUND & AIMS

Anorectal manometry (ARM) is a comprehensive diagnostic tool for evaluating patients with constipation, fecal incontinence, or anorectal pain; however, it is not widely utilized for reasons that remain unclear. The aim of this roundtable discussion was to critically examine the current clinical practices of ARM and biofeedback therapy by physicians and surgeons in both academic and community settings.

METHODS

Leaders in medical and surgical gastroenterology and physical therapy with interest in anorectal disorders were surveyed regarding practice patterns and utilization of these technologies. Subsequently, a roundtable was held to discuss survey results, explore current diagnostic and therapeutic challenges with these technologies, review the literature, and generate consensus-based recommendations.

RESULTS

ARM identifies key pathophysiological abnormalities such as dyssynergic defecation, anal sphincter weakness, or rectal sensory dysfunction, and is a critical component of biofeedback therapy, an evidence-based treatment for patients with dyssynergic defecation and fecal incontinence. Additionally, ARM has the potential to enhance health-related quality of life and reduce healthcare costs. However, it has significant barriers that include a lack of education and training of healthcare providers regarding the utility and availability of ARM and biofeedback procedures, as well as challenges with condition-specific testing protocols and interpretation. Additional barriers include understanding when to perform, where to refer, and how to use these technologies, and confusion over billing practices.

CONCLUSIONS

Overcoming these challenges with appropriate education, training, collaborative research, and evidence-based guidelines for ARM testing and biofeedback therapy could significantly enhance patient care of anorectal disorders.

Characteristics associated with subjective and objective measures of treatment success in women undergoing percutaneous tibial nerve stimulation vs sham for accidental bowel leakage

INTRODUCTION AND HYPOTHESIS

In randomized trials both percutaneous tibial nerve stimulation (PTNS) and sham result in clinically significant improvements in accidental bowel leakage (ABL). We aimed to identify subgroups who may preferentially benefit from PTNS in women enrolled in a multicenter randomized trial.

METHODS

This planned secondary analysis explored factors associated with success for PTNS vs sham using various definitions: treatment responder using three cutoff points for St. Mark's score (≥3-, ≥4-, and ≥5-point reduction); Patient Global Impression of Improvement (PGI-I) of ≥ much better; and ≥50% reduction in fecal incontinence episodes (FIEs). Backward logistic regression models were generated using elements with significance of p<0.2 for each definition and interaction terms assessed differential effects of PTNS vs sham.

RESULTS

Of 166 women randomized, 160 provided data for at least one success definition. Overall, success rates were 65% (102 out of 158), 57% (90 out of 158), and 46% (73 out of 158) for ≥3-, ≥4-, and ≥5-point St Mark's reduction respectively; 43% (68 out of 157) for PGI-I; and 48% (70 out of 145) for ≥50% FIEs. Of those providing data for all definitions of success, 77% (109 out of 142) met one success criterion, 43% (61 out of 142) two, and 29% (41 out of 142) all three success criteria. No reliable or consistent factors were associated with improved outcomes with PTNS over sham regardless of definition.

CONCLUSIONS

Despite exploring diverse success outcomes, no subgroups of women with ABL differentially responded to PTNS over sham. Success results varied widely across subjective and objective definitions. Further investigation of ABL treatment success definitions that consistently and accurately capture patient symptom burden and improvement are needed.

Outcomes of graciloplasty in the treatment of fecal incontinence: a systematic review and meta-analysis of the literature

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.

Severity and impact of accidental bowel leakage two decades after no, one, or two sphincter injuries

BACKGROUND

Information about the long-term severity and subjective impact of anal incontinence in women after 1 or 2 consecutive obstetrical anal sphincter injuries is still scarce and contradictory.

OBJECTIVE

This study aimed to describe the severity and impact of anal incontinence among women with 2 previous deliveries 2 decades after birth and to analyze the relative effect of 1 vs 2 obstetrical anal sphincter injuries in comparison with no obstetrical anal sphincter injuries and the possible influence of obstetrical anal sphincter injury on other pelvic floor disorders.

STUDY DESIGN

We linked prospectively registered data in the Swedish Medical Birth Register with information from a postal and web-based questionnaire in 2015. Statistics Sweden identified women with 2 vaginal births from 1992 to 1998, and a simple random sample of 11,000 women was drawn from a source cohort of 64,687 women. To achieve equal-sized groups of women with 1 or 2 obstetrical anal sphincter injuries, the latter group was oversampled from 1987 to 2000. The final study cohorts consisted of 6760 women with no obstetrical anal sphincter injury, 357 women with 1 injury, and 324 women with 2 obstetrical anal sphincter injuries. Third- and fourth-degree perineal tears were grouped together for analysis. Anal incontinence was defined as either fecal or isolated gas incontinence, and fecal incontinence was defined as involuntary leakage of solid or liquid stool with or without concomitant gas. Frequencies of leakage of stool and gas were dichotomized into low frequency (less than once a month) and high frequency (several times a month or more often). Pairwise comparisons were analyzed using Fisher exact tests, Mantel-Haenszel statistics, and the Mann-Whitney U test. Trends were analyzed using Mantel-Haenszel statistics and the Spearman rank correlation test. Logistic regression models were used to obtain the age- and body-mass-index -adjusted odds ratios for outcomes. Statistical significance was set at P<.05.

RESULTS

The response rate was 65.5% in the randomly selected cohort and 70.1% among women with 2 obstetrical anal sphincter injuries. Bothersome fecal incontinence occurred in 3.3% (212/6458) of women without obstetrical anal sphincter injury, in 10.4% (36/345) (adjusted odds ratio, 3.25; 95% confidence interval, 2.23-4.73) of those with 1 injury, and in 16.5% (52/315) (adjusted odds ratio, 5.16; 95% confidence interval, 3.69-7.22) of those with 2 obstetrical anal sphincter injuries (trend P<.0001). Fecal incontinence was perceived as bothersome in 28.2% (212/753) of women without an obstetrical anal sphincter injury compared with in 43.9% (36/82) and 46.0% (52/113) of those with 1 or 2 obstetrical anal sphincter injuries (trend P<.0001). Leakage of liquid stool occurred in 10.8% (724/6717) of those without injury, in 21.7% (77/355) of women with 1 injury, and 34.9% (113/324) of women with 2 obstetrical anal sphincter injuries (trend P<.0001). Incontinence affecting daily life was reported by 8.6% (577/6672) of women without injury and by 19.7% (69/351) and 29.6% (96/324) of women with 1 and 2 sphincter injuries, respectively (trend P<.0001). The mean Jorge-Wexner score was 2.44, 3.26, and 3.88 for women with no, 1, or 2 sphincter injuries (trend P<.0001). Among women with a Jorge-Wexner score of 6, >50% had bothersome anal incontinence. The adjusted odds ratio for the overall effect of 1 vs 2 obstetrical anal sphincter injuries on measures of anal incontinence was 2.19 (95% confidence interval, 1.68-2.85) and 3.91 (95% confidence interval, 3.06-5.00), respectively, when compared with no obstetrical anal sphincter injury (both P<.0001). Having 1 or 2 obstetrical anal sphincter injuries had no significant effect on other pelvic floor disorders or on lower urinary tract symptoms (P=.73 and P=.69).

CONCLUSION

A consistent additive effect of 1 or 2 sphincter injuries on the severity and impact of anal incontinence was observed in women 2 decades after 2 vaginal births. This information is important for healthcare economics, clinical practice, and policy.

The relationship between fecal incontinence and food insecurity in United States women: an analysis of 2005-2010 National Health and Nutrition Examination Survey

BACKGROUND

Fecal incontinence is a prevalent debilitating pelvic floor disorder characterized by the involuntary loss of stool. Fecal incontinence is known to be associated with constipation and loose stool, advancing age, chronic comorbidities, and previous anorectal trauma, among other biologic risk factors. The relationship between social determinants of health, such as food insecurity, and fecal incontinence is not well elucidated.

OBJECTIVE

This study aimed to investigate the association between fecal incontinence and food insecurity using a nationally representative sample of US adult women. Our secondary aim was to examine the role of diet by assessing dietary differences between participants with and without fecal incontinence and between food-insecure women with and without fecal incontinence.

STUDY DESIGN

This study analyzed data from the National Health and Nutrition Examination Survey, a nationally representative series of cross-sectional health surveys. Fecal incontinence was defined as accidental leakage of stool within the last 30 days. Food insecurity was assessed using the household food security measure created by the US Department of Agriculture. Dietary data from the National Health and Nutrition Examination Survey dietary interviews titled "Individual Foods, First Day" and "Individual Foods, Second Day," which estimate the foods and drinks consumed in the preceding 24 hours, were pooled. The association between fecal incontinence and food insecurity was analyzed using logistic regression after controlling for patient characteristics.

RESULTS

Overall, 3216 women were included, representing nearly 130 million US women. Of these women, 10.9% had fecal incontinence. There was no significant difference in diet between women with and without fecal incontinence (p>0.05). Food-insecure women in the overall sample reported higher carbohydrate and sugar intake and lower fiber and alcohol intake (all P<.05). Among food-insecure women, those with fecal incontinence had higher calorie and total fats intake than those without fecal incontinence; there was no significant difference in other dietary components (p>0.05). There was a significant association between food insecurity and fecal incontinence, such that women with food insecurity had higher odds of fecal incontinence after adjusting for patient characteristics and diet (odds ratio, 1.76; 95% confidence interval, 1.17-2.66; P=.008).

CONCLUSION

Food insecurity was associated with fecal incontinence even after accounting for diet. Understanding the role of social determinants of health in fecal incontinence symptomatology and treatment is important to potentially alleviate symptom burden and improve the quality of life in at-risk populations.

Benign Anorectal Disorder Management in Low-Resource Settings

There are many benign anorectal disorders, which can make patients seek care. In low-resource settings, the incidence of those pathologies is not different from the industrialized and western world. However, an interesting difference colorectal surgeons and gastroenterologists can face is the fact that many patients do not seek help or are not aware and have little opportunities to be helped. Latin America population is estimated to be around 8% of the world population, with Brazil having the largest percentage. Infectious diseases, which were previously under control or were steadily declining, have emerged. For example, we have seen resurgence of dengue, malaria, and syphilis in pregnancy, as well as other sexually transmitted diseases that can affect the anorectal region. In this article, we will address the most common benign anorectal disorders.

Functional bowel disorders with diarrhoea: Clinical guidelines of the United European Gastroenterology and European Society for Neurogastroenterology and Motility

Irritable bowel syndrome with diarrhoea (IBS‐D) and functional diarrhoea (FDr) are the two major functional bowel disorders characterized by diarrhoea. In spite of their high prevalence, IBS‐D and FDr are associated with major uncertainties, especially regarding their optimal diagnostic work‐up and management. A Delphi consensus was performed with experts from 10 European countries who conducted a literature summary and voting process on 31 statements. Quality of evidence was evaluated using the grading of recommendations, assessment, development, and evaluation criteria. Consensus (defined as >80% agreement) was reached for all the statements. The panel agreed with the potential overlapping of IBS‐D and FDr. In terms of diagnosis, the consensus supports a symptom‐based approach also with the exclusion of alarm symptoms, recommending the evaluation of full blood count, C‐reactive protein, serology for coeliac disease, and faecal calprotectin, and consideration of diagnosing bile acid diarrhoea. Colonoscopy with random biopsies in both the right and left colon is recommended in patients older than 50 years and in presence of alarm features. Regarding treatment, a strong consensus was achieved for the use of a diet low fermentable oligo‐, di‐, monosaccharides and polyols, gut‐directed psychological therapies, rifaximin, loperamide, and eluxadoline. A weak or conditional recommendation was achieved for antispasmodics, probiotics, tryciclic antidepressants, bile acid sequestrants, 5‐hydroxytryptamine‐3 antagonists (i.e. alosetron, ondansetron, or ramosetron). A multinational group of European experts summarized the current state of consensus on the definition, diagnosis, and management of IBS‐D and FDr.

Percutaneous Tibial Nerve Stimulation vs Sham Stimulation for Fecal Incontinence in Women: NeurOmodulaTion for Accidental Bowel Leakage Randomized Clinical Trial

INTRODUCTION

To determine whether percutaneous tibial nerve stimulation (PTNS) is superior to sham stimulation for the treatment of fecal incontinence (FI) in women refractory to first-line treatments.

METHODS

Women aged 18 years or older with ≥3 months of moderate-to-severe FI that persisted after a 4-week run-in phase were randomized 2:1 (PTNS:sham stimulation) to 12 weekly 30-minute sessions in this multicenter, single-masked, controlled superiority trial. The primary outcome was change from baseline FI severity measured by St. Mark score after 12 weeks of treatment (range 0-24; minimal important difference, 3-5 points). The secondary outcomes included electronic bowel diary events and quality of life. The groups were compared using an adjusted general linear mixed model.

RESULTS

Of 199 women who entered the run-in period, 166 (of 170 eligible) were randomized, (111 in PTNS group and 55 in sham group); the mean (SD) age was 63.6 (11.6) years; baseline St. Mark score was 17.4 (2.7); and recording was 6.6 (5.5) FI episodes per week. There was no difference in improvement from baseline in St. Mark scores in the PTNS group when compared with the sham group (-5.3 vs -3.9 points, adjusted difference [95% confidence interval] -1.3 [-2.8 to 0.2]). The groups did not differ in reduction in weekly FI episodes (-2.1 vs -1.9 episodes, adjusted difference [95% confidence interval] -0.26 [-1.85 to 1.33]). Condition-specific quality of life measures did not indicate a benefit of PTNS over sham stimulation. Serious adverse events occurred in 4% of each group.

DISCUSSION

Although symptom reduction after 12 weeks of PTNS met a threshold of clinical importance, it did not differ from sham stimulation. These data do not support the use of PTNS as conducted for the treatment of FI in women.

Fecal Incontinence: Pathogenesis, Diagnosis, and Updated Treatment Strategies

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.

ACG Clinical Guidelines: Management of Benign Anorectal Disorders

Benign anorectal disorders of structure and function are common in clinical practice. These guidelines summarize the preferred approach to the evaluation and management of defecation disorders, proctalgia syndromes, hemorrhoids, anal fissures, and fecal incontinence in adults and represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence for these guidelines was assessed using the Grading of Recommendations Assessment, Development and Evaluation process. When the evidence was not appropriate for Grading of Recommendations Assessment, Development and Evaluation, we used expert consensus to develop key concept statements. These guidelines should be considered as preferred but are not the only approaches to these conditions.

Accidental Bowel Leakage/Fecal Incontinence: Evidence-Based Management

Fecal incontinence is a highly prevalent and debilitating condition that negatively impacts quality of life. The etiology is often multifactorial and treatment can be hindered by lack of understanding of its mechanisms and available treatment options. This article reviews the evidence-based update for the management of fecal incontinence.

Evaluation of mobile applications for patients with fecal incontinence using a modified APPLICATIONS scoring system

INTRODUCTION AND HYPOTHESIS

Mobile applications (apps) are becoming an increasingly popular means of obtaining medical information. The aim of our study was to identify and evaluate patient-centered fecal incontinence (FI) mobile apps using a modified APPLICATIONS scoring system.

METHODS

We conducted searches in the Apple App and Google Play stores to identify FI-related mobile apps using search terms reflecting both commonly accepted medical terms as well as colloquial terms used by our patients with FI. Apps that were in English, relevant to FI, patient-centered, and medically accurate were included. Each eligible app was then independently evaluated by the three authors using a modified 17-point APPLICATIONS scoring system.

RESULTS

We identified 2785 apps upon initial search using FI search terms. Fourteen apps met eligibility criteria for scoring. Most apps were bowel movement trackers (13/14, 93%), of which only three allowed for tracking of FI episodes. Only one (7%) app contained educational information specific to FI. Ten (71%) apps were fully functional at no cost. Thirteen (93%) apps cited literature. Median APPLICATIONS score was 10 (IQR 9-11). "BristolStoolChart," "FreeToBe," and "PoopLog" each received the highest total score of 13.

CONCLUSIONS

Patient-centered mobile apps that provide FI-specific educational information or allow for FI symptom tracking are scarce. While we did discover some accurate sources of information and means of tracking bowel habits, patients are likely to encounter inaccurate or irrelevant information even when searching for FI-related apps using appropriate terminology. Future app development should include FI-specific symptom tracking and educational information from reputable sources.

Design of a Randomized Controlled Trial of Percutaneous Posterior Tibial Nerve Stimulation for the Treatment of Refractory Fecal Incontinence in Women: The NeurOmodulaTion for Accidental Bowel Leakage Study

OBJECTIVES

High-level evidence for second-line noninvasive treatments for fecal incontinence in women is limited. We present the rationale for and design of the NeuromOdulaTion for Accidental Bowel Leakage trial, a randomized controlled trial of percutaneous tibial nerve stimulation (PTNS) and validated sham stimulation in women with refractory accidental bowel leakage.

METHODS

The rationale and goals for a 2-part study with a run-in phase, use of a generic pulse generator for PTNS and sham stimulation, masking, participant inclusion, primary and secondary outcome measures, and adverse event collection are described. A superiority design will be used to compare change from baseline in St. Mark's score after 12 weekly stimulation sessions between PTNS and sham. Responders to initial treatment (PTNS or sham) will be assigned to scheduled or "as needed" intervention for up to 1 year. Secondary outcome measures include incontinence episodes and other bowel events recorded in a 14-day electronic bowel diary, general and condition-specific quality of life instruments, adaptive behavior, global impression of improvement, symptom control, and sexual function.

RESULTS

Sample size calculations determined that 165 participants (110 PTNS and 55 sham) would provide 90% power to detect greater than or equal to 4-point difference between PTNS and sham in change from baseline in St. Mark's score at 12 weeks.

CONCLUSIONS

The methods for the NeuromOdulaTion for Accidental Bowel Leakage trial will provide high-level evidence of the effectiveness and optimal maintenance therapy schedule of a low-cost PTNS protocol in community-dwelling women seeking second-line intervention for refractory accidental bowel leakage.

Need for Awareness and Training in Women's Gastrointestinal Health: A Call to Action

Women's gastrointestinal (GI) health is a topic that is not well understood nor taught in most training programs. In this article, we highlight the importance of proper training in women's GI health among gastroenterologists and fellows, and identify some common conditions to provide the best possible treatment for their female patients.

Enhancing the identification of anal incontinence in women of reproductive age

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.

Surgical Treatment Alternatives to Sacral Neuromodulation for Fecal Incontinence: Injectables, Sphincter Repair, and Colostomy

Fecal incontinence is a prevalent health problem that affects over 20% of healthy women. Many surgical treatment options exist for fecal incontinence after attempts at non-operative management. In this article, the authors discuss surgical treatment options for fecal incontinence other than sacral neuromodulation.

Tools for fecal incontinence assessment: lessons for inflammatory bowel disease trials based on a systematic review

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.

Performance, acceptability, and validation of a phone application bowel diary

AIMS

To assess performance, acceptability, external validity, and reliability of a phone application electronic bowel diary (PFDN Bowel eDiary).

METHODS

Women reporting refractory accidental bowel leakage (ABL) were enrolled in a randomized, crossover trial evaluating paper versus eDiary documentation of bowel movements (BM) and fecal incontinence episodes (FIE). Events were characterized by the presence or absence of urgency and Bristol stool scale consistency. The eDiary entries were date/time stamped and prompted by twice-daily phone notifications. Women were randomized to complete up to three consecutive 14-day diaries in two sequences. Diary events were compared between formats using the Pearson correlation. System usability scale (SUS) assessed eDiary usability. The eDiary test-retest reliability was assessed with intraclass correlations (ICCs).

RESULTS

Paired diary data were available from 60/69 (87%) women 63.8 ± 9.8 years old with mean 13.2 BM per week and 6.5 FIE per week (nearly half with urgency). Among those providing diaries, adherence did not differ by paper or eDiary (93.3% vs. 95.0%). Notifications prompted 29.6% of eDiary entries, improving adherence from 70% to 95%. Paper and eDiaries were moderate to-strongly correlated for BMs per week (r = .61), urgency BMs per week (r = .76), FIE per week (r = .66), urgency FIE per week (r = .72). Test-retest reliability was good (ICC = .81 BMs per week, .79 urgency BMs per week, .74 FIE per week, and .62 urgency FIE per week). The mean SUS score was high, 82.3 ± 17.5 (range, 0-100) with 91.4% rating it easy to use, and 75.9% preferring the eDiary over paper.

CONCLUSION

The PFDN Bowel eDiary correlated well with paper diary was considered easy to use, preferred to paper diaries, had high rates of confirmed real-time diary completion that obviated staff data entry.

Updates in treating fecal incontinence in women

PURPOSE OF REVIEW

Fecal incontinence is a chronic condition that can significantly affect a woman's quality of life. The pathogenesis of fecal incontinence is multifaceted and management ranges from supportive care, medical therapy to more invasive surgical procedures. This review will discuss the recent advancements in treating fecal incontinence.

RECENT FINDINGS

The pelvic floor disorder consortium has created a consensus document with recommendations on pelvic floor symptom measurement tools, patient-reported instruments, and questionnaires that should be used when evaluating fecal incontinence. There is new robust data reinforcing the importance of conservative management prior to proceeding with more invasive treatment. Lastly, several novel therapies that were developed in the past decade now have longer term data on safety and efficacy.

SUMMARY

Management of fecal incontinence is challenging, as no one therapy has been proven to be predominately effective. We should continue to first optimize patients with conservative therapy followed by induction of more advanced therapies. There needs to be continued efforts to develop and evaluate effective treatment guidelines and therapies for fecal incontinence.

Management of Fecal Incontinence

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.

The mysteries of menopause and urogynecologic health: clinical and scientific gaps

OBJECTIVES

A significant body of knowledge implicates menopausal estrogen levels in the pathogenesis of the common pelvic floor disorders (PFDs). These health conditions substantially decrease quality of life, increase depression, social isolation, caregiver burden, and economic costs to the individuals and society.

METHODS

This review summarizes the epidemiology of the individual PFDs with particular attention to the understanding of the relationship between each PFD and menopausal estrogen levels, and the gaps in science and clinical care that affect menopausal women. In addition, we review the epidemiology of recurrent urinary tract infection (rUTI)-a condition experienced frequently and disproportionately by menopausal women and hypothesized to be potentiated by menopausal estrogen levels.

RESULTS

The abundance of estrogen receptors in the urogenital tract explains why the natural reduction of endogenous estrogen, the hallmark of menopause, can cause or potentiate PFDs and rUTIs. A substantial body of epidemiological literature suggests an association between menopause, and PFDs and rUTIs; however, the ability to separate this association from age and other comorbid conditions makes it difficult to draw definitive conclusions on the role of menopause alone in the development and/or progression of PFDs. Similarly, the causative link between the decline in endogenous estrogen levels and the pathogenesis of PFDs and rUTIs has not been well-established.

CONCLUSIONS

Innovative human studies, focused on the independent effects of menopausal estrogen levels, uncoupled from tissue and cellular senescence, are needed.

Small-Group, Community-Member Intervention for Urinary and Bowel Incontinence: A Randomized Controlled Trial

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.

Effects of Extracorporeal Magnetic Stimulation in Fecal Incontinence

Background

Fecal incontinence (FI) is a common condition that has devastating consequences for patients’ QOL. In some patients, the conventional functional pelvic floor electrical stimulation has been effective but is an invasive and embarrassing treatment. The object of the study was to evaluate the feasibility of functional extracorporeal magnetic stimulation (FMS) in strengthening the pelvic floor muscles without an anal plug and the embarrassment of undressing.

Materials and Methods

Thirty patients (26 female and 4 males) with FI were enrolled. All patients were assessed during a specialized coloproctology evaluation followed by endoanal ultrasonography and anorectal manometry. All patients underwent an FMS treatment once weekly for 8 weeks. Patients’ outcome was assessed by the Cleveland Clinic Fecal Incontinence Score (CCFIS) and by the fecal incontinence QOL questionnaire (FIQL).

Results

After 8 weeks, the number of solid and liquid stool leakage per week was significantly reduced (p<0.05) with a significant improvement of the CCFIS and of the FIQL (p<0.05). Moreover, the authors recorded a missed recruitment of the agonist and antagonists’ defecation muscles.

Conclusion

FMS is a safe, non-invasive and painless treatment for FI. It could be recommended for selected patients with non-surgical FI to ensure a rapid clinical improvement.

ACOG Practice Bulletin No. 210: Fecal Incontinence

Fecal incontinence, or the involuntary leakage of solid or loose stool, is estimated to affect 7-15% of community-dwelling women (1). It is associated with reduced quality of life, negative psychologic effects, and social stigma (2), yet many women do not report their symptoms or seek treatment. Less than 3% of women who do self-report fecal incontinence will have this diagnosis recorded in their medical record (3). Obstetrician-gynecologists are in a unique position to identify women with fecal incontinence because pregnancy, childbirth, obstetric anal sphincter injuries (OASIS), and pelvic floor dysfunction are important risk factors that contribute to fecal incontinence in women. The purpose of this Practice Bulletin is to provide evidence-based guidelines on the screening, evaluation, and management of fecal incontinence to help obstetrician-gynecologists diagnose the condition and provide conservative treatment or referral for further work up and surgical management when appropriate. For discussion on fecal incontinence associated with OASIS, see Practice Bulletin No. 198, Prevention and Management of Obstetric Lacerations at Vaginal Delivery (4).

Placebo Response Rates in Electrical Nerve Stimulation Trials for Fecal Incontinence and Constipation: A Systematic Review and Meta-Analysis

BACKGROUND

Successful treatments following electrical nerve stimulation have been commonly reported in patients with fecal incontinence and constipation. However, many of these nerve stimulation trials have not implemented sham controls, and are, therefore, unable to differentiate overall treatment responses from placebo. This systematic review aimed to quantify placebo effects and responses following sham electrical nerve stimulation in patients with fecal incontinence and constipation.

MATERIAL AND METHODS

A literature search of Ovid MEDLINE, PubMed, EMBASE, and Cochrane databases was conducted from inception to April 2017. Randomized sham-controlled trials investigating the effect of lower gastrointestinal electrical nerve stimulation in fecal incontinence and constipation were included. Pediatric and non-sham controlled trials were excluded.

RESULTS

Ten randomized sham-controlled trials were included. Sham stimulation resulted in improvements in fecal incontinence episodes by 1.3 episodes per week (95% CI -2.53 to -0.01, p = 0.05), fecal urgency by 1.5 episodes per week (CI -3.32 to 0.25, p = 0.09), and Cleveland Clinic Severity scores by 2.2 points (CI 1.01 to 3.36, p = 0.0003). Sham also improved symptoms of constipation with improved stool frequency (1.3 episodes per week, CI 1.16 to 1.42, p < 0.00001), Wexner Constipation scores (5.0 points, CI -7.45 to -2.54 p < 0.0001), and Gastrointestinal Quality of Life scores (7.9 points, CI -0.46 to 16.18, p = 0.06).

CONCLUSIONS

Sham stimulation is associated with clinical and statistically meaningful improvements in symptoms of fecal incontinence and constipation, as well as quality of life scores, highlighting the importance of sham controls in nerve stimulation trials. Noncontrolled studies should be interpreted with caution.

The anatomy of Trans-Obturator Posterior Anal Sling (TOPAS) and dynamics of potential mechanism of action

BACKGROUND

The aim of this study was to investigate the course of the transobturator posterior anal sling and its relationship to anatomical structures.

METHODS

The transobturator anal sling procedure was performed in four fresh-frozen pelvises. The pelvises were dissected and the structures adjacent to the sling and the course of the sling were identified and measurements obtained.

RESULTS

The transobturator posterior anal sling was inserted 2 ± 0.5 cm posteriorly to the anus, and 2.5 ± 0.5 cm caudal to the coccyx under the levator plate at the level of the puborectalis muscle. The tape was 3.5 ± 0.5 cm from the pubic symphysis and 2.3 ± 0.3 cm from the obturator canal at entry into the pelvic cavity. The tape passed 2.3 ± 0.3 cm inferior-medial to the obturator canal. At entry, the sling passed lateral to the ischiopubic ramus through the following structures: gracilis, adductor brevis, obturator externus, obturator membrane, and beneath the obturator internus muscle. The sling traveled 2-3 ± 0.5 cm over the iliococcygeus muscle and perforated the iliococcygeus fibers 0-2 cm medial to arcus tendinous levator ani. The posterior division of the obturator nerve was 2.8 ± 0.7 cm from the tape. The anterior division of the obturator nerve was 3.4 ± 0.8 cm from the tape. The device passed 1.1 ± 0.4 cm from the most medial branch of the obturator vessels.

CONCLUSIONS

The transobturator posterior anal sling travels mostly in the avascular area of the ischiorectal fossa and posterior to the puborectalis muscle as intended.

Effectiveness of Autologous Fat Graft in Treating Fecal Incontinence

Purpose

The most common risk factor for fecal incontinence (FI) is obstetric injury. FI affects 1.4%–18% of adults. Most patients are unaware when they are young, when symptoms appear suddenly and worsen with aging. Autologous fat graft is widely used in cosmetic surgical field and may substitute for injectable bulky agents in treating FI. Authors have done fat graft for past several years. This article reports the effectiveness of the fat graft in treating FI and discusses satisfaction with the procedure.

Methods

Fat was harvested from both lateral thighs using 10-mL Luer-loc syringe. Pure fat was extracted from harvests and mixed with fat, oil, and tumescent through refinement. Fats were injected into upper border of posterior ano-rectal ring, submucosa of anal canal and intersphincteric space. Thirty-five patients with FI were treated with this method from July 2016 to February 2017 in Busan Hangun Hospital. They were 13 male (mean age, 60.8 years) and 22 female patients (mean age, 63.3 years). The Wexner score was checked before procedure. We evaluated outcome in outpatients by asking the patients. For 19 patients we checked the Wexner score after procedure.

Results

Symptom improved in 29 (82.9%), and not improved in 6 (17.1%). In 2 of 6 patients, they felt better than before procedure, although not satisfied. No improvement in 4. Mean Wexner score was 9.7 before procedure. There were no serious complications such as inflammation or fat embolism.

Conclusion

Autologous fat graft can be an effective alternative treatment for FI. It is safe and easy to perform, and cost effective.

Mechanical inserts for the treatment of faecal incontinence: A systematic review

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

Practice patterns in the diagnosis and treatment of fecal incontinence with sacral neuromodulation: Can urologists impact this gap in care?

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.

Anal Sphincteroplasty in the Minimally Invasive Era: Assessment of National Trends and Complications

Fecal incontinence is a debilitating and underreported condition. Despite introduction of novel therapies in recent years, anal sphincteroplasty (AS) remains the surgical choice for certain patients. Previous reports have primarily focused on single-surgeon or single-center experience with AS. The purpose of this study was to assess patient characteristics and perioperative outcomes of AS using a national cohort. Patients (n = 586) who underwent AS as a primary procedure between 2009 and 2015 were identified by the CPT code as recorded in the study and were evaluated and examined for association with 30-day complications. The number of sphincteroplasties performed decreased seven-fold between 2009 and 2015. Wound infection, wound dehiscence, and urinary tract infection were the most common complications, occurring in 30 (5.1%), 12 (2.1%), and 6 (1%) patients, respectively. Preoperative steroid use and surgeon specialty were associated with wound complications on multivariate analysis. We present the first national study of patients undergoing AS and identify factors that predispose to wound complications. In addition, we demonstrate that the number of anal sphincteroplasties performed in the United States is decreasing dramatically, likely because of novel therapy for fecal incontinence. We hope that this study will assist in patient counseling and call attention to preserving surgical training as utilization of AS rapidly declines.

Management of sacrococcygeal pilonidal sinus disease

The ideal treatment for patients who suffer from pilonidal sinus disease should lead to a cure with a rapid recovery period allowing a return to normal daily activities, with a low level of associated morbidity. A variety of different surgical techniques have been described for the primary treatment of pilonidal sinus disease and current practice remains variable and contentious. Whilst some management options have improved outcomes for some patients, the complications of surgery, particularly related to wound healing, often remain worse than the primary disease. This clinical review aims to provide an update on the management options to guide clinicians involved in the care of patients who suffer from sacrococcygeal pilonidal sinus disease.

Anal incontinence after vaginal delivery or cesarean section

INTRODUCTION

Uncertainties remain as to whether a cesarean section is protective for the short-term and long-term development of anal incontinence. Our aim was to explore whether women who had delivered only vaginally were at greater risk of anal incontinence than nulliparous women and women who had undergone cesarean sections only.

MATERIAL AND METHODS

Background information, medical history, and data on anal incontinence (defined as fecal or flatus incontinence weekly or more) reported by women participating in a large population-based health survey in Norway (the Nord-Trøndelag Health Study 3) during the period October 2006 to June 2008 were collected and linked to data from the Medical Birth Registry of Norway. The prevalence of anal incontinence was calculated and multivariate logistic regression analyses were applied.

RESULTS

The mean age of the 12 567 women was 49.9 years. The age and educational level of women who had cesarean sections only were similar to those who had a vaginal delivery and obstetric anal sphincter injuries (OASIS). Nulliparous women and those who had a vaginal delivery and no OASIS were older and had higher educational achievements than women who had delivered by cesarean section exclusively, and women with OASIS. One in four women with OASIS reported anal incontinence compared with one in six of the other women (P < .001). Age, educational level, diarrhea, constipation, birthweight, and OASIS increased the risk of anal incontinence in all women. Parity was associated with anal incontinence in parous women only. No differences were found for fecal urgency.

CONCLUSIONS

Women with vaginal deliveries complicated by OASIS are at increased risk of anal incontinence. However, no increased risk of anal incontinence was found in nulliparous women or women who had cesarean sections only or vaginal deliveries not complicated by OASIS.

If We Don't Ask, They Won't Tell: Screening for Urinary and Fecal Incontinence by Primary Care Providers

BACKGROUND

More than half of older adults experience urinary (UI) or fecal incontinence (FI), but the majority have never discussed symptoms with health care providers. Little is known about primary care providers' (PCPs') screening for UI and FI.

METHODS

We conducted a cross-sectional electronic survey of PCPs within a Midwest academic institution to ascertain and compare PCPs' beliefs, attitudes, and behaviors regarding screening and treatment for UI and FI; determine factors associated with screening for FI; and identify potential barriers to and facilitators of FI screening and treatment.

RESULTS

Among 154 PCPs, the screening rate for UI (75%) was more than double that for FI (35%; P < .001). PCPs believed that both UI and FI screening were important but felt better informed to treat UI (P < .001). Screening for FI was associated with UI screening (OR, 11.27; 95% CI, 4.9-26.0; P < .001); feeling informed to treat FI (OR, 10.21; 95% CI, 1.2-90.0; P = .01); screening verbally (OR, 3.9; 95% CI, 1.9-8.0; P < .001); perceiving screening as important (OR, 3.7; 95% CI, 1.8-7.4; P < .001); using the term, "accidental bowel leakage" (OR, 2.9; 95% CI, 1.2-6.7; P = .02) or "bowel control issues" (OR, 2.2; 95% CI, 1.1-4.5; P = .03); and being a resident (OR, 0.37; 95% CI, 0.16-0.82; P = .02). PCPs reported high interest in patient and provider educational materials about UI and FI.

CONCLUSIONS

Most PCPs screen for UI but not FI. High reported interest in educational materials, coupled with high reported rates of perceived importance of screening for UI and FI, suggests that PCPs welcome informative interventions to streamline diagnosis and treatment.

Prevalence of and Factors Associated With Fecal Incontinence: Results From a Population-Based Survey

BACKGROUND & AIMS

Fecal incontinence (FI) is characterized by uncontrolled passage of solid or liquid stool. We aimed to determine the prevalence and severity of FI in a large sample of US residents.

METHODS

We recruited a representative sample of patients in October 2015 to complete the National Gastrointestinal (GI) Survey; a mobile app called MyGiHealth was used to systematically collect data on GI symptoms. FI was defined as accidental leakage of solid or liquid stool. Severity of FI was determined by responses to the National Institutes of Health FI Patient Reported Outcomes Measurement Information System questionnaire. Multivariable regression models were used to identify factors associated with FI prevalence and severity.

RESULTS

Among 71,812 individuals who completed the National GI Survey, 14.4% reported FI in the past; of these, 33.3% had FI within the past 7 days. Older age, male sex, and Hispanic ethnicity increased the likelihood of having FI within the past week. Individuals with Crohn's disease, ulcerative colitis, celiac disease, irritable bowel syndrome, or diabetes were more likely to report FI. Non-Hispanic black and Hispanic individuals and individuals with Crohn's disease, celiac disease, diabetes, human immunodeficiency virus/acquired immunodeficiency syndrome, or chronic idiopathic constipation had more severe symptoms of FI than individuals without these features.

CONCLUSIONS

In a large population-based survey, 1 in 7 people reported previous FI. FI is age-related and more prevalent among individuals with inflammatory bowel disease, celiac disease, irritable bowel syndrome, or diabetes than people without these disorders. Proactive screening for FI among these groups is warranted.

Neuromodulation and female pelvic disorders

PURPOSE OF REVIEW

Sacral neuromodulation is a Food and Drug administration approved therapy for the treatment of refractory overactive bladder, urinary retention, and fecal incontinence. The objective of this manuscript is to review the recent literature regarding clinical outcome data and current management strategies for sacral neuromodulation.

RECENT FINDINGS

There have been significant advances in therapy techniques as well as long-term data supporting this therapy for both urinary and fecal incontinence. These include the InSite trial and the long-term follow-up of the fecal incontinence registry trial. In addition, the development of surgical techniques to reduce infection, improvements in programmability of the implantable pulse generator, as well as deciding on best stimulation parameters will be discussed. Finally, introduction of a new animal model to test a chronically implanted lead and stimulator in a large animal model opens the door to many future studies.

SUMMARY

These data help to inform us on the most recent clinical outcomes for sacral neuromodulation, as well as recommendations for best practices for implant technique.

Fecal incontinence knowledge, attitudes, and help-seeking behaviors among community-dwelling adults in Korea

OBJECTIVES

Fecal incontinence (FI) is a common debilitating disorder that tends to be underreported. Although low health literacy likely contributes to the underreporting, studies on FI knowledge among the general population remain scarce. We investigated how FI knowledge is associated with attitudes and help-seeking behaviors.

METHODS

We conducted a cross-sectional survey among community-dwelling adults undergoing national health screening in Korea. A structured, self-administered questionnaire was used to assess FI knowledge, attitudes, and help-seeking behaviors. Odds ratios (ORs; 95% confidence intervals, CIs) were estimated using logistic regression with adjustment for covariables.

RESULTS

Of the 601 participants completing the survey, only 29.8% were aware of the term FI, and their knowledge levels were insufficient. As for FI-related attitudes, 24.6% considered FI to be very rare, and 22.3% considered it to be moderately or less distressing. Individuals who knew the term FI tended to consider FI more common (OR: 2.45; 95%CI: 1.49-4.02) and distressing (OR: 1.68; 95%CI: 1.07-2.63) than those without knowledge. Assuming future FI occurrence, those considering FI to be distressing were less willing to ignore or self-manage the condition (OR: 0.25; 95%CI: 0.11-0.58). Among patients with FI (n = 83), only 30.1% had sought help and 8.4% had consulted doctors. Knowing the term FI was significantly associated with overall help-seeking behavior (OR: 9.23; 95%CI: 2.09-40.77).

CONCLUSIONS

FI knowledge levels and help-seeking rates were low among community-dwelling adults. FI knowledge was significantly associated with attitudes and help-seeking behaviors. Future public education programs are warranted to improve FI knowledge, attitudes, and help-seeking behaviors.

Factors Associated With Efficacy of Percutaneous Tibial Nerve Stimulation for Fecal Incontinence, Based on Post-Hoc Analysis of Data From a Randomized Trial

BACKGROUND & AIMS

A recent randomized, multi-center, phase 3 trial, performed in the United Kingdom (Control of Fecal Incontinence using Distal Neuromodulation Trial), demonstrated no significant clinical benefit of percutaneous tibial nerve stimulation (PTNS) compared to sham stimulation in patients with fecal incontinence (FI). However, this study did not analyze predictors of response. We used data from this trial to identify factors that predict the efficacy of PTNS in adults with FI.

METHODS

The study population comprised 205 patients from the CONtrol of Fecal Incontinence using Distal NeuromodulaTion Trial. The primary outcome was a binary indicator of success (≥50% reduction in weekly FI episodes after 12 weeks of treatment) or failure, as per the original trial characteristics including baseline FI symptom type, defecatory urgency, and co-existent symptoms of baseline liquid stool consistency and obstructive defecation (OD) were defined a priori. Univariable and multivariable analyses were performed to explore these factors as predictors of response to PTNS and sham.

RESULTS

In both univariable and multivariable analysis, the presence of OD symptoms negatively predicted outcome in patients who received PTNS (OR, 0.38; 95% CI, 0.16-0.91; P = .029), and positively predicted sham response (OR, 3.45; 95% CI, 1.31-9.21; P = .012). No other tested variable affected outcome. Re-analysis of the primary outcome excluding patients with OD symptoms (n = 112) resulted in a significant clinical effect of PTNS compared to sham (48.9% vs 18.2% response, P = .002; multivariable OR, 4.71; 95% CI, 1.71-12.93; P = .003).

CONCLUSIONS

Concomitant OD symptoms negatively affected the clinical outcome of PTNS vs sham in a major randomized controlled trial. Future appropriately designed studies could further explore this observation with potential for future stratified patient selection.

Electrical stimulation structurally affects the tissues of the rectum and anus of nulliparous rats

Considering that the muscles of the anus perform a critical role in maintaining continence, losses in their structure can negatively affect the physiological control of the intestinal contents. Anorectal electro-stimulation (ARES) has been reported to have a positive effect on the functionality of treated patients, but how ARES affects the structural tissues of the anorectal segment remains unknown. Because the study of how ARES structurally affects human tissues is not possible, this study aimed to clarify these effects in a murine model, which has a similar anorectal segment (structure and physiology) to humans. For the descriptive and comparative study, randomly selected nulliparous adult Wistar rats (n = 5) were submitted to 30 anorectal sessions of ARES with a biphasic current (700 μs, 50 Hz from 2 to 4 mA). After treatment, the animals were euthanized, and the anorectal segments were dissected and processed for histopathological analysis. Our results showed that ARES increased the widths of the mucosal, submucosal and muscle layers of the rectum, as well as the number of leukocytes in the mucosa. ARES also caused hyperplasia of the smooth muscle of the internal anal sphincter and hypertrophy of the external anal sphincter muscle. In conclusion, our results showed that ARES had not only a positive effect on the structure (morphology) of all tissues associated with the rectum and anus but, more importantly, on the structural gain of the muscles (hyperplasia and hypertrophy), which could point to a functional gain of the anal sphincter, reinforcing the applicability of ARES as a non-invasive treatment for anal incontinence.

Can three-dimensional high-resolution anorectal manometry detect anal sphincter defects in patients with faecal incontinence?

AIM

Endoanal ultrasound (EAUS) is the gold standard for detecting anal sphincter defects in patients with faecal incontinence (FI), while anorectal manometry evaluates sphincter function. Three-dimensional high-resolution anorectal manometry (3D HRAM) is a newer modality with the potential to assess both sphincter function and anatomy. The purpose of the present study was to compare 3D HRAM with 3D EAUS for the detection of anal sphincter defects in patients with FI.

METHOD

A linkage analysis was performed between the 3D HRAM and 3D EAUS databases of a tertiary referral centre to identify patients with FI who underwent both 3D EAUS and 3D HRAM. With 3D HRAM, a defect was defined as any pressure measurement below 25 mmHg at rest with at least 18° of continuous expansion. The 3D HRAM findings were compared with those of 3D EAUS.

RESULTS

The study cohort included 39 patients with a mean age of 64.7 ± 15.2 years (SD); and 31 (79%) were female. Eight (21%) patients had an anal sphincter defect on EAUS with a median size of 93° (range 40°-136°). Fourteen (36%) had a defect shown by 3D HRAM with a median size of 144° (36°-180°). The sensitivity, specificity and positive and negative predictive values of 3D HRAM in detecting a sphincter defect were 75%, 74%, 43% and 92%, respectively.

CONCLUSION

With a negative predictive value of 92%, 3D HRAM may be a useful screening method for ruling out a sphincter defect in patients with FI, thereby avoiding both EAUS and manometry in selected patients.

Faecal incontinence in patients with a sphincter defect: comparison of sphincteroplasty and sacral nerve stimulation

AIM

Sphincteroplasty (SP) is used to treat faecal incontinence (FI) in patients with a sphincter defect. Although sacral nerve stimulation (SNS) is used in patients, its outcome in patients with a sphincter defect has not been definitively evaluated. We compared the results of SP and SNS for FI associated with a sphincter defect.

METHOD

Patients treated by SNS or SP for FI with an associated sphincter defect were retrospectively identified from an Institutional Review Board approved prospective database. Patients with ultrasound evidence of a sphincter defect were matched by age, gender and body mass index. The main outcome measure was change in the Cleveland Clinic Florida Faecal Incontinence Score (CCF-FIS).

RESULTS

Twenty-six female patients with a sphincter defect were included in the study. The 13 patients in each group were similar for age, body mass index, initial CCF-FIS and the duration of follow-up. No differences were observed in parity (P = 1.00), the rate of concomitant urinary incontinence (P = 0.62) or early postoperative complications. Within-group analysis showed a significant reduction of the CCF-FIS among patients having SNS (15.9-8.4; P = 0.003) but not SP (16.9-12.9; P = 0.078). There was a trend towards a more significant improvement in CCF-FIS in the SNS than in the SP group (post-treatment CCF-FIS 8.4 vs 12.9, P = 0.06). Net improvement in CCF-FIS was not significantly different between the groups (P = 0.06).

CONCLUSION

Significant improvement in CCF-FIS was observed in patients treated with SNS but not SP patients. A trend towards better results was seen with SNS.

Pathophysiology and Therapeutic Options for Fecal Incontinence

Fecal incontinence (FI), defined as the involuntary loss of solid or liquid feces through the anus is a prevalent condition with significant effects on quality of life. FI can affect individuals of all ages and in many cases greatly impairs quality of life but, incontinent patients should not accept their debility as either inevitable or untreatable. The severity of incontinence can range from unintentional elimination of flatus to the complete evacuation of bowel contents. It is reported to affect up to 18% of the population, with a prevalence reaching as high as 50% in nursing home residents. However, FI is often underreported, thus obscuring its true prevalence in the general population. The options for treatment vary according to the degree and severity of the FI. Treatment can include dietary and lifestyle modification, certain medications, biofeedback therapy, bulking agent injections, sacral nerve stimulation as well as various types of surgery. In this article, we aim to provide a comprehensive review on the diagnosis and management of FI.