Sacral nerve stimulation for faecal incontinence: from voodoo to evidence-based medicine

The Three Axial Perineal Evaluation (TAPE) score: a new scoring system for comprehensive evaluation of pelvic floor function

AIM

Abnormalities of one pelvic floor compartment are usually associated with anomalies in the other compartments. Therapies which specifically address one clinical problem may potentially adversely affect other pelvic floor activities. A new comprehensive holistic scoring system defining global pelvic function is presented.

METHOD

A novel scoring system with a software program is presented expressing faecal, urinary and gynaecological functions as a geometric polygon based on symptom-specific questionnaires [the three axial pelvic evaluation (TAPE) score] where differences in overall geometric area vary from normal. After validation in healthy volunteers, its clinical performance was tested on patients with obstructed defaecation, genital prolapse and urinary/faecal incontinence treated by the stapled transanal rectal resection (STARR) procedure, colpo-hysterectomy and sacral nerve modulation, respectively. The TAPE score was correlated with the Pelvic Floor Impact Questionnaire 7 quality of life score.

RESULTS

There was good inter-observer variation and internal consistency between two observers recording the TAPE score in normal volunteers. In the STARR patients, constipation improved but the TAPE score was unchanged because of deterioration in other pelvic floor functions leading to an unchanged overall postoperative recorded quality of life. Conversely, incontinent patients treated with sacral nerve stimulation improved their function showing concomitant improvements in TAPE scores and quality of life indices. Similar correlative improvements were noted in patients undergoing hysterectomy for genital prolapse.

CONCLUSION

The TAPE score defines the impact of symptom-specific treatments on the pelvic floor and may provide an opportunity for comparison of clinical data between units and in clinical trials of specific medical and surgical pelvic floor management.

Percutaneous tibial nerve stimulation for fecal incontinence: a video demonstration

BACKGROUND

Fecal incontinence is an increasingly common condition with significant negative impact on quality on life and health care resources. It frequently presents a therapeutic challenge to clinicians. Emerging evidence suggests that percutaneous tibial nerve stimulation is an effective treatment for fecal incontinence with the added benefit of being minimally invasive and cost effective.

METHOD

Pursuant to the preliminary report of our early experience of percutaneous tibial nerve stimulation in patients with fecal incontinence published in this journal in 2010, in this dynamic article, we now describe and demonstrate the actual technique that can be performed in a nurse-led clinic or outpatient or community setting.

CONCLUSION

Percutaneous tibial nerve stimulation is a technically simple procedure that can potentially be performed in an outpatient or community setting. The overall early success rate of 68% following its use reported by our unit compares favorably with the success rate following other forms of neuromodulation, including sacral nerve stimulation. When completed, our long-term outcome data will provide further information on the efficacy of tibial nerve stimulation in a larger cohort of patients (n > 100). Future studies, including our currently planned randomized controlled trial of percutaneous tibial nerve stimulation vs sham stimulation, will provide controlled efficacy data and may provide information on its exact mechanism of action.