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Margalit-Yehuda R, Maradey-Romero C, Davidov Y, Ram E, Carter D. Comparison of etiological and physiological characteristics of fecal incontinence in men and women. Am J Physiol Gastrointest Liver Physiol 2024; 326:G274-G278. [PMID: 38193161 DOI: 10.1152/ajpgi.00113.2023] [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: 05/31/2023] [Revised: 12/08/2023] [Accepted: 12/21/2023] [Indexed: 01/10/2024]
Abstract
Fecal incontinence (FI) is often underreported and underestimated in men. Our aims were to clarify the causes and the physiological characteristics of FI in men and to underline the differences between etiological and physiological factors in men and women diagnosed with FI. The study cohort encompassed 200 men and 200 women who underwent anatomical and physiological evaluation for FI in a tertiary referral center specializing in pelvic floor disorders. All patients underwent endoanal ultrasound and anorectal manometry. Evacuation proctography was performed in some patients. Demographic, medical, anatomical, and physiological parameters were compared between the two study groups. Urge incontinence was the most frequent type of FI in both genders. In men, anal fistula, history of anal surgeries, rectal tumors, and pelvic radiotherapy were common etiologic factors, whereas history of pelvic surgeries was more common in women. Associated urinary incontinence was reported more frequently by women. External anal sphincter defects, usually anterior, were more common in women (M: 1.5%, F: 24%, P < 0.0001), whereas internal anal sphincter defect prevalence was similar in men and women (M: 6%, F: 12%, P = 0.19). Decreased resting and squeeze pressures were less common in men (M: 29%, F: 46%, P < 0.0001: M: 44%, F: 66%, P < 0.0001). The incidence of rectal hyposensitivity was higher in men (M: 11.1%, F: 2.8%, P < 0.0001), whereas rectal hypersensitivity was higher in women (M: 5.8%, F: 10.8%, P < 0.0001). Anorectal dyssynergia was more common in men (M: 66%, F: 37%, P < 0.0001). Significantly different etiological factors and physiological characteristics for FI were found in men. Acknowledging these differences is significant and may yield better treatment options.NEW & NOTEWORTHY Fecal incontinence (FI) in men has different etiological factors when compared with women. The prevalence of internal anal sphincter defect among men with FI was similar to women. Different manometric measurements were found among men with FI: decreased anal pressures were less common among men, whereas rectal hyposensitivity and anorectal dyssynergia were more common among men.
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Affiliation(s)
- Reuma Margalit-Yehuda
- Department of Gastroenterology, Sheba Medical Center, Tel HaShomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Carla Maradey-Romero
- Department of Gastroenterology, Sheba Medical Center, Tel HaShomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yana Davidov
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Liver Diseases Center, Sheba Medical Center, Tel HaShomer, Israel
| | - Edward Ram
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Surgery and Transplantations, Sheba Medical Center, Tel HaShomer, Israel
| | - Dan Carter
- Department of Gastroenterology, Sheba Medical Center, Tel HaShomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Rasijeff AMP, García‐Zermeño K, Di Tanna G, Remes‐Troche J, Knowles CH, Scott MS. Systematic review and meta-analysis of anal motor and rectal sensory dysfunction in male and female patients undergoing anorectal manometry for symptoms of faecal incontinence. Colorectal Dis 2022; 24:562-576. [PMID: 35023242 PMCID: PMC9303800 DOI: 10.1111/codi.16047] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 12/16/2021] [Accepted: 12/22/2021] [Indexed: 02/01/2023]
Abstract
AIM Manometry is the best established technique to assess anorectal function in faecal incontinence. By systematic review, pooled prevalences of anal hypotonia/hypocontractility and rectal hypersensitivity/hyposensitivity in male and female patients were determined in controlled studies using anorectal manometry. METHODS Searches of MEDLINE and Embase were completed. Screening, data extraction and bias assessment were performed by two reviewers. Meta-analysis was performed based on a random effects model with heterogeneity evaluated by I2 . RESULTS Of 2116 identified records, only 13 studies (2981 faecal incontinence patients; 1028 controls) met the inclusion criteria. Anal tone was evaluated in 10 studies and contractility in 11; rectal sensitivity in five. Only three studies had low risk of bias. Pooled prevalence of anal hypotonia was 44% (95% CI 32-56, I2 = 96.35%) in women and 27% (95% CI 14-40, I2 = 94.12%) in men. The pooled prevalence of anal hypocontractility was 69% (95% CI 57-81; I2 = 98.17%) in women and 36% (95% CI 18-53; I2 = 96.77%) in men. Pooled prevalence of rectal hypersensitivity was 10% (95% CI 4-15; I2 = 80.09%) in women and 4% (95% CI 1-7; I2 = 51.25%) in men, whereas hyposensitivity had a pooled prevalence of 7% (95% CI 5-9; I2 = 0.00%) in women compared to 19% (95% CI 15-23; I2 = 0.00%) in men. CONCLUSIONS The number of appropriately controlled studies of anorectal manometry is small with fewer still at low risk of bias. Results were subject to gender differences, wide confidence intervals and high heterogeneity indicating the need for international collective effort to harmonize practice and reporting to improve certainty of diagnosis.
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Affiliation(s)
- Annika M. P. Rasijeff
- National Bowel Research Centre and GI Physiology UnitBlizard InstituteCentre for Neuroscience, Surgery & TraumaQueen Mary University of LondonLondonUK
| | - Karla García‐Zermeño
- National Bowel Research Centre and GI Physiology UnitBlizard InstituteCentre for Neuroscience, Surgery & TraumaQueen Mary University of LondonLondonUK
| | - Gian‐Luca Di Tanna
- George Institute for Global HealthUniversity of New South WalesSydneyNew South WalesAustralia
| | - José Remes‐Troche
- Instituto de Investigaciones Médico BiológicasUniversidad VeracruzanaVeracruzMéxico
| | - Charles H. Knowles
- National Bowel Research Centre and GI Physiology UnitBlizard InstituteCentre for Neuroscience, Surgery & TraumaQueen Mary University of LondonLondonUK
| | - Mark S. Scott
- National Bowel Research Centre and GI Physiology UnitBlizard InstituteCentre for Neuroscience, Surgery & TraumaQueen Mary University of LondonLondonUK
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Brochard C, Mege D, Bridoux V, Meurette G, Damon H, Lambrescak E, Faucheron JL, Trilling B, Lehur PA, Wyart V, Sielezneff I, Mion F, Etienney I, Leroi AM, Siproudhis L. Is Sacral Nerve Modulation a Good Option for Fecal Incontinence in Men? Neuromodulation 2019; 22:745-750. [PMID: 31318471 DOI: 10.1111/ner.13017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 05/09/2019] [Accepted: 05/15/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The objective was to assess the efficacy and the safety of sacral nerve modulation (SNM) in men with fecal incontinence (FI) compared with those of SNM in women. METHOD Prospectively collected data from patients from seven tertiary colorectal units who underwent an implant procedure between January 2010 and December 2015 were reviewed retrospectively. Outcomes and surgical revision and definitive explantation rates were compared between men and women. RESULTS A total of 469 patients (60 men [12.8%]; mean age = 61.4 ± 12.0 years) were included in the study, 352 (78.1%) (31 men [8.8%]) of whom received a permanent implant. The ratio of implanted/tested men was significantly lower than the ratio of implanted/tested women (p = 0.0004). After a mean follow-up of 3.4 ± 1.9 years, the cumulative successful treatment rates tended to be less favorable in men than in women (p = 0.0514): 88.6% (75.6-95.1), 75.9% (60.9-86.4), 63.9% (48.0-77.3), and 43.9% (26.7-62.7) at one, two, three, and five years, respectively, in men; 92.0% (89.1-94.2), 84.2% (80.3-87.4), 76.8% (72.3-80.7), and 63.6% (57.5-69.3) at one, two, three, and five years, respectively, in women. The revision rate for infection and the definitive explantation rate for infection were higher in men than in women (p = 0.0001 and p = 0.0024, respectively). CONCLUSION Both short- and long-term success rates of SNM for FI were lower in men than in women. The revision and definitive explantation for long-term infection rates were significantly higher in men.
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Affiliation(s)
- Charlène Brochard
- Department of Digestive Physiology and Department of Gastroenterology, University Hospital of Rennes Pontchaillou, CIC1414, INPHY, INSERM U1241, University of Rennes 1, Rennes, France
| | - Diane Mege
- Department of Digestive Surgery, Assistance Publique Hôpitaux de Marseille, Timone University Hospital, Marseille, France
| | - Valérie Bridoux
- Normandie Univ, UNIROUEN, Inserm U1073, Rouen University Hospital, Department of Digestive Surgery, Rouen, France
| | - Guillaume Meurette
- Clinique de Chirurgie Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, University Hospital of Nantes, Nantes, France
| | - Henri Damon
- Université de Lyon, Hospices Civils de Lyon, Digestive Physiology, Hospital E Herriot, Lyon, France
| | - Elsa Lambrescak
- Department of Coloproctology, Groupe Hospitalier Diaconesses Croix Saint-Simon, Paris, France
| | - Jean-Luc Faucheron
- Department of Surgery, Colorectal Unit, Michallon University Hospital, Grenoble, France.,University Grenoble Alps UMR 5525, CNRS, TIMC-IMAG, Grenoble, France
| | - Bertrand Trilling
- Department of Surgery, Colorectal Unit, Michallon University Hospital, Grenoble, France.,University Grenoble Alps UMR 5525, CNRS, TIMC-IMAG, Grenoble, France
| | - Paul-Antoine Lehur
- Clinique de Chirurgie Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, University Hospital of Nantes, Nantes, France.,Department of General Surgery, Ospedale Civico di Lugano, Lugano, Switzerland
| | - Vincent Wyart
- Clinique de Chirurgie Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, University Hospital of Nantes, Nantes, France
| | - Igor Sielezneff
- Department of Digestive Surgery, Assistance Publique Hôpitaux de Marseille, Timone University Hospital, Marseille, France
| | - François Mion
- Université de Lyon, Hospices Civils de Lyon, Digestive Physiology, Hospital E Herriot, Lyon, France
| | - Isabelle Etienney
- Department of Coloproctology, Groupe Hospitalier Diaconesses Croix Saint-Simon, Paris, France
| | - Anne-Marie Leroi
- Normandie Univ, UNIROUEN, Inserm U1073, Rouen University Hospital, Department of Digestive Surgery, Rouen, France
| | - Laurent Siproudhis
- Department of Digestive Physiology and Department of Gastroenterology, University Hospital of Rennes Pontchaillou, CIC1414, INPHY, INSERM U1241, University of Rennes 1, Rennes, France
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Abstract
BACKGROUND Although care of urological disorders in spina bifida is well established, there is yet no agreement on a standardized approach to bowel dysfunction in this population. OBJECTIVE The purpose of this study was to assess bowel dysfunction using validated instruments and the risk factors in adults with spina bifida. DESIGN A multidisciplinary team prospectively collected patient data, focusing on anorectal and urological symptoms. SETTINGS The study was conducted with data from a French referral center for spina bifida. PATIENTS A total of 228 adults with spina bifida (sex ratio men:women, 92 (40%):136 (60%)) with a median age of 34.7 years (range, 26.8-44.7 y) were assessed. MAIN OUTCOMES MEASURES Factors associated with severe fecal incontinence (Cleveland Clinic Incontinence Score ≥9) and severe bowel dysfunction (Neurogenic Bowel Dysfunction score ≥14) were assessed in a multivariate analysis model. RESULTS The prevalence rates of severe fecal incontinence and severe bowel dysfunction were 60% (130/217) and 42% (71/168). Bowel dysfunction was the second most common major concern of patients after lower urinary tract dysfunction. Male sex, obesity, urinary incontinence, and a Knowles-Eccersley-Scott symptom constipation score ≥10 were independently associated with severe fecal incontinence. Patients with soft stools had significantly less severe bowel dysfunction. Neither neurologic level nor other neurologic features of spina bifida were associated with severe fecal incontinence or severe bowel dysfunction. LIMITATIONS The recruitment of patients with spina bifida through a national referral center might have resulted in selection bias, and some data were missing especially regarding BMI and Neurogenic Bowel Dysfunction score (21% and 26% of missing data). CONCLUSIONS The prevalence rates of severe fecal incontinence and severe bowel dysfunction in adults with spina bifida were high and were adequately perceived by the patients. The present study emphasized the association of bowel dysfunction and fecal incontinence with obesity, urologic disorders, and stool consistency rather than neurologic features. See Video Abstract at http://links.lww.com/DCR/A394.
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Abstract
BACKGROUND Men with passive fecal leakage represent a distinct clinical entity in which the pathophysiology remains unclear. Standard anorectal investigations fail to demonstrate consistent abnormalities in this group. Anal acoustic reflectometry is a new test of anal sphincter function with greater sensitivity and discriminatory ability than conventional anal manometry. OBJECTIVE The aim of this study was to determine whether men with fecal leakage have an abnormality in anal sphincter function that is detectable by anal acoustic reflectometry. DESIGN This was an age-matched study of continent and incontinent men. SETTINGS The study was conducted at a university teaching hospital. PATIENTS Male patients with isolated symptoms of fecal leakage were recruited. Anal acoustic reflectometry, followed by conventional anal manometry, was performed. Results were then compared with those from an age-matched group of men with no symptoms of anal incontinence or anorectal pathology. MAIN OUTCOME MEASURES Variables measured with anal acoustic reflectometry and anal manometry in the incontinent and continent men were compared. RESULTS Thirty subjects were recruited, of whom 15 were men with fecal leakage and 15 were continent men. There was a significantly higher incidence of previous anorectal surgery in the men with leakage. The anal acoustic reflectometry variables of opening and closing pressure were significantly lower in leakers compared with continent subjects (p = 0.003 and p = 0.001). Hysteresis was significantly greater in the male leaker group (p = 0.026). No difference was seen in anal manometry. LIMITATIONS With a larger sample size, the effect of previous anorectal surgery and the presence of an anal sphincter defect could be clarified. CONCLUSIONS Anal acoustic reflectometry is a sensitive test of anal sphincter function and, unlike anal manometry, can discriminate male leakers from continent subjects. An identifiable abnormality has been detected using anal acoustic reflectometry, which may further our understanding of the pathogenesis in this group.
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Mazor Y, Jones M, Andrews A, Kellow JE, Malcolm A. Novel insights into fecal incontinence in men. Am J Physiol Gastrointest Liver Physiol 2017; 312:G46-G51. [PMID: 27881404 DOI: 10.1152/ajpgi.00362.2016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 11/21/2016] [Indexed: 01/31/2023]
Abstract
UNLABELLED Fecal incontinence (FI) in men is common, yet data on sex differences in clinical features, physiology, and treatment are scarce. Our aim was to provide insights into FI in males compared with females. Prospectively collected data from 73 men and 596 women with FI in a tertiary referral center were analyzed. Anorectal physiology, clinical characteristics, and outcome of instrumented biofeedback (BF) were recorded. Thirty-one men with FI proceeded to BF and were matched with 62 age-matched women with FI who underwent BF. Men with FI had higher resting, squeeze, and cough anal sphincter pressures (P < 0.001) and were more able to hold a sustained squeeze compared with women (P = 0.04). Men with FI had higher rectal pressure and less inadequate rectal pressure on strain and higher sensory thresholds (P < 0.05). Men, but not women, with isolated soiling had higher anal resting and squeeze pressures compared with those with overt FI (P < 0.05). Men were less likely to undergo BF when offered compared with women. Baseline symptom severity did not differ between the groups. In men, the absence of an organic cause for the FI and the presence of overt FI, but not isolated soiling, were correlated with improvement in patient satisfaction following BF. The outcomes of 50% reduction in FI episodes, physician assessment, symptoms, and quality of life scores after BF all significantly improved in men similarly to women. We conclude that men, compared with women, with FI have unique clinical features and physiology and are less likely to have investigations and treatment despite successful outcome with BF. Future studies to customize treatment in males and determine barriers to therapy are warranted. NEW & NOTEWORTHY Fecal incontinence in men is common, yet data on sex differences in clinical features, physiology, and treatment are scarce. We provide evidence that men, compared with women, with fecal incontinence have unique clinical features and physiology and are less likely to have investigations and treatment despite successful outcome with anorectal biofeedback therapy.
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Affiliation(s)
- Yoav Mazor
- Neurogastroenterology Unit, Royal North Shore Hospital, St Leonards, New South Wales, Australia; .,University of Sydney, Sydney, New South Wales, Australia; and
| | - Michael Jones
- Psychology Department, Macquarie University, Sydney, New South Wales, Australia
| | - Alison Andrews
- Neurogastroenterology Unit, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - John E Kellow
- Neurogastroenterology Unit, Royal North Shore Hospital, St Leonards, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia; and
| | - Allison Malcolm
- Neurogastroenterology Unit, Royal North Shore Hospital, St Leonards, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia; and
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Townsend DC, Carrington EV, Grossi U, Burgell RE, Wong JYJ, Knowles CH, Scott SM. Pathophysiology of fecal incontinence differs between men and women: a case-matched study in 200 patients. Neurogastroenterol Motil 2016; 28:1580-8. [PMID: 27206812 DOI: 10.1111/nmo.12858] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 04/20/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Fecal incontinence (FI) is a common and socially disabling condition with obstetric trauma considered the principal etiological factor. This study aimed to systematically evaluate symptom presentation and anorectal function in both females and males with FI. METHODS One hundred males (M) and 100 age-matched females (F) with FI presenting between 2012 and 2014 were identified from a prospectively collected database. Comparison of clinical (history, symptom profile, and severity using validated questionnaires) and anorectal physiological (manometry, rectal sensory testing, endoanal ultrasonography, and evacuation proctography) data between M and F was performed. KEY RESULTS Incidence of prior anal surgery (M: 28% vs F: 18%, p = 0.13) and abdominal surgery (M: 25% vs F: 26%, p = 0.90) was similar between sexes, but females had a higher incidence of previous pelvic surgery (M: 4% vs F: 47%, p < 0.001). Eighty-five females were parous and 75% reported history of traumatic vaginal delivery. There was a trend toward higher St Mark's incontinence scores in females (mean ± SD; M: 13 ± 4 vs F: 14 ± 5, p = 0.06). In men, structural sphincter abnormalities were uncommon (M: 37% vs F: 77%, p < 0.001), while impaired rectal sensation (M: 24% vs F: 7%, p = 0.001) and functional disturbances of evacuation (M: 36% vs F: 13%, p = 0.001) were more common than in women. No abnormality on all tests performed was observed in twice as many males (M: 18% vs F: 9%, p = 0.10). CONCLUSIONS & INFERENCES Pathophysiological mechanisms of FI differ between sexes. Anal sphincter dysfunction was an uncommon finding in males, with impaired rectal sensation and functional disturbances of evacuation much more prominent than in the female cohort. These findings are likely to impact options for symptom management.
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Affiliation(s)
- D C Townsend
- National Bowel Research Centre (NBRC) and GI Physiology Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - E V Carrington
- National Bowel Research Centre (NBRC) and GI Physiology Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - U Grossi
- National Bowel Research Centre (NBRC) and GI Physiology Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.
| | - R E Burgell
- National Bowel Research Centre (NBRC) and GI Physiology Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - J Y J Wong
- National Bowel Research Centre (NBRC) and GI Physiology Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - C H Knowles
- National Bowel Research Centre (NBRC) and GI Physiology Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - S M Scott
- National Bowel Research Centre (NBRC) and GI Physiology Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Rao SS, Bharucha AE, Chiarioni G, Felt-Bersma R, Knowles C, Malcolm A, Wald A. Functional Anorectal Disorders. Gastroenterology 2016; 150:S0016-5085(16)00175-X. [PMID: 27144630 PMCID: PMC5035713 DOI: 10.1053/j.gastro.2016.02.009 10.1053/j.gastro.2016.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 02/09/2016] [Indexed: 01/11/2024]
Abstract
This report defines criteria and reviews the epidemiology, pathophysiology, and management of common anorectal disorders: fecal incontinence (FI), functional anorectal pain and functional defecation disorders. FI is defined as the recurrent uncontrolled passage of fecal material for at least 3 months. The clinical features of FI are useful for guiding diagnostic testing and therapy. Anorectal manometry and imaging are useful for evaluating anal and pelvic floor structure and function. Education, antidiarrheals and biofeedback therapy are the mainstay of management; surgery may be useful in refractory cases. Functional anorectal pain syndromes are defined by clinical features and categorized into three subtypes. In proctalgia fugax, the pain is typically fleeting and lasts for seconds to minutes. In levator ani syndrome (LAS) and unspecified anorectal pain the pain lasts more than 30 minutes, but in LAS there is puborectalis tenderness. Functional defecation disorders are defined by >2 symptoms of chronic constipation or irritable bowel syndrome with constipation, and with >2 features of impaired evacuation i.e., abnormal evacuation pattern on manometry, abnormal balloon expulsion test or impaired rectal evacuation by imaging. It includes two subtypes; dyssynergic defecation and inadequate defecatory propulsion. Pelvic floor biofeedback therapy is effective for treating LAS and defecatory disorders.
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Rao SS, Bharucha AE, Chiarioni G, Felt-Bersma R, Knowles C, Malcolm A, Wald A. Functional Anorectal Disorders. Gastroenterology 2016; 150:S0016-5085(16)00175-X. [PMID: 27144630 PMCID: PMC5035713 DOI: 10.1053/j.gastro.2016.02.009] [Citation(s) in RCA: 266] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 02/09/2016] [Indexed: 12/12/2022]
Abstract
This report defines criteria and reviews the epidemiology, pathophysiology, and management of common anorectal disorders: fecal incontinence (FI), functional anorectal pain and functional defecation disorders. FI is defined as the recurrent uncontrolled passage of fecal material for at least 3 months. The clinical features of FI are useful for guiding diagnostic testing and therapy. Anorectal manometry and imaging are useful for evaluating anal and pelvic floor structure and function. Education, antidiarrheals and biofeedback therapy are the mainstay of management; surgery may be useful in refractory cases. Functional anorectal pain syndromes are defined by clinical features and categorized into three subtypes. In proctalgia fugax, the pain is typically fleeting and lasts for seconds to minutes. In levator ani syndrome (LAS) and unspecified anorectal pain the pain lasts more than 30 minutes, but in LAS there is puborectalis tenderness. Functional defecation disorders are defined by >2 symptoms of chronic constipation or irritable bowel syndrome with constipation, and with >2 features of impaired evacuation i.e., abnormal evacuation pattern on manometry, abnormal balloon expulsion test or impaired rectal evacuation by imaging. It includes two subtypes; dyssynergic defecation and inadequate defecatory propulsion. Pelvic floor biofeedback therapy is effective for treating LAS and defecatory disorders.
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Chumpitazi BP, Self MM, Czyzewski DI, Cejka S, Swank PR, Shulman RJ. Bristol Stool Form Scale reliability and agreement decreases when determining Rome III stool form designations. Neurogastroenterol Motil 2016; 28:443-8. [PMID: 26690980 PMCID: PMC4760857 DOI: 10.1111/nmo.12738] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 10/30/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Rater reproducibility of the Bristol Stool Form Scale (BSFS), which categorizes stools into one of seven types, is unknown. We sought to determine reliability and agreement by individual stool type and when responses are categorized by Rome III clinical designation as normal or abnormal (constipation or diarrhea). METHODS Thirty-four gastroenterology providers from three institutions rated 35 stool photographs using the BSFS. Twenty rerated the photographs. KEY RESULTS 1190 individual stool type ratings were completed. Though only four photographs had absolute agreement (all Type 1 or Type 7), general agreement was high with 1132 (95.1%) of ratings being within one category type of the modal rating. Inter-rater and intra-rater reliability of the BSFS by individual stool type was excellent with intraclass correlations of 0.88 (95% CI: 0.86-0.90, p < 0.001) and 0.89 (95% CI: 0.86-0.91, p < 0.001), respectively. However, agreement decreased when using Rome III designations with 13 (37%) photographs having significantly diverging classifications (semi-interquartile range = 0.5). These 13 photographs were rated by the majority of raters as either type 2 vs type 3 or type 5 vs type 6 stools, representing the boundaries of normal vs abnormal stools. Inter-rater and intra-rater reliability of the BSFS by Rome III clinical categorization decreased with intraclass correlations of 0.75 (95% CI: 0.69-0.81, p < 0.001) and 0.65 (95% CI: 0.49-0.81, p < 0.001), respectively. CONCLUSIONS & INFERENCES The Bristol Stool Form Scale has excellent reliability and agreement when used to rate individual stool type by raters. However, BSFS reliability and agreement decreases when determining Rome III stool form categories.
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Affiliation(s)
- Bruno P. Chumpitazi
- Department of Pediatrics, Baylor College of Medicine, Houston, TX,Section of Gastroenterology, Hepatology, and Nutrition, Texas Children’s Hospital, Houston, TX
| | - Mariella M. Self
- Department of Pediatrics, Baylor College of Medicine, Houston, TX,Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX
| | - Danita I. Czyzewski
- Department of Pediatrics, Baylor College of Medicine, Houston, TX,Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX,Section of Gastroenterology, Hepatology, and Nutrition, Texas Children’s Hospital, Houston, TX
| | - Sydney Cejka
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Paul R. Swank
- University of Texas School of Public Health, Houston, TX
| | - Robert J. Shulman
- Department of Pediatrics, Baylor College of Medicine, Houston, TX,Section of Gastroenterology, Hepatology, and Nutrition, Texas Children’s Hospital, Houston, TX,Children’s Nutrition Research Center, Houston, TX
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Gourcerol G, Granier S, Bridoux V, Menard JF, Ducrotté P, Leroi AM. Do endoflip assessments of anal sphincter distensibility provide more information on patients with fecal incontinence than high-resolution anal manometry? Neurogastroenterol Motil 2016; 28:399-409. [PMID: 26670599 DOI: 10.1111/nmo.12740] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 10/30/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND Anal manometry is the standard technique for evaluating anal sphincter function. However, the functional lumen imaging probe (EndoFLIP(®) ) can be used to measure sphincter distensibility during volume-controlled distensions. Our aims were (i) to assess anal distensibility in patients with fecal incontinence (FI) and in healthy subjects using the EndoFLIP(®) and (ii) to compare the results with anal pressures measured by 3D high-resolution manometry (3D-HRM) to determine whether the EndoFLIP(®) was more sensitive and specific for diagnosing FI than 3D-HRM. METHODS EndoFLIP(®) and 3D-HRM assessments of 34 female FI patients and 40 healthy female subjects were performed. Anal distensibility was measured as the median cross-sectional area at the narrowest point divided by the corresponding intra-bag pressure at rest and during peak voluntary contraction and was expressed in mm(2) /mmHg. KEY RESULTS A 40-mL anal distensibility index was selected for further comparisons as it provided the best discrimination between the FI patients and the healthy subjects. The index was significantly higher in the FI patients than in the healthy subjects at rest (p = 1.10(-4) ) and during voluntary contraction (p = 1.10(-4) ). The index at rest and during voluntary contraction appeared to be more appropriate than anal pressures for discriminating between FI patients and healthy subjects. CONCLUSIONS & INFERENCES The present study confirmed that FI is associated with an abnormally high distensibility index at rest and during voluntary contraction. The ability of the distensibility index to discriminate between FI patients and healthy subjects was significantly better than anal pressure.
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Affiliation(s)
- G Gourcerol
- INSERM U1073, Service de Physiologie Digestive, CHU Rouen, INSERM CIC 0204 Rouen, Rouen, France
| | - S Granier
- INSERM U1073, Service de Physiologie Digestive, CHU Rouen, INSERM CIC 0204 Rouen, Rouen, France
| | - V Bridoux
- INSERM U1073, Service de Chirurgie Digestive, CHU Rouen, Rouen, France
| | | | - P Ducrotté
- INSERM U1073, Service d'Hépato-Gastroentérologie, CHU Rouen, Rouen, France
| | - A M Leroi
- INSERM U1073, Service de Physiologie Digestive, CHU Rouen, INSERM CIC 0204 Rouen, Rouen, France
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Cohan JN, Chou AB, Varma MG. Faecal incontinence in men referred for specialty care: a cross-sectional study. Colorectal Dis 2015; 17:802-9. [PMID: 25757510 DOI: 10.1111/codi.12943] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 01/31/2015] [Indexed: 02/08/2023]
Abstract
AIM Little is known about men with faecal incontinence. We compared clinical findings and quality of life in a large cohort of men and women with faecal incontinence to guide its evaluation and treatment in men. METHOD We analysed men and women presenting to a tertiary referral centre with faecal incontinence between 2005 and 2013. Demographics, physical examination, anorectal physiology testing, symptom severity (Fecal Incontinence Severity Index) and quality of life (Fecal Incontinence Quality of Life Scale) were recorded. We determined differences between men and women and analysed the association between gender and quality of life. RESULTS Data were obtained from 144 men and 897 women. Men with faecal incontinence were slightly younger than women (55.3 vs 57.6 years, P = 0.001), more likely to report coexisting constipation (P = 0.004) and more likely to have normal internal and external sphincter function on physical examination (both P < 0.001). Anorectal physiology testing revealed fewer sphincter defects (P < 0.05) and less pudendal neuropathy (P < 0.05) in men compared with women. Although symptom severity and overall quality of life were similar, men had improved coping and less embarrassment compared with women after we adjusted for important clinical factors. CONCLUSION Men with faecal incontinence presenting to a tertiary referral centre are more likely than women to have a mixed presentation characterized by constipation and less sphincter dysfunction. They exhibited better coping and less embarrassment than women. These findings should be taken into consideration when evaluating and treating men with faecal incontinence.
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Affiliation(s)
- J N Cohan
- Philip R. Lee Institute for Health Policy Studies and Department of Surgery, University of California, San Francisco, California, USA
| | - A B Chou
- Department of Surgery, University of California, San Francisco, California, USA
| | - M G Varma
- Section of Colorectal Surgery, Department of Surgery, University of California, San Francisco, California, USA
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Loganathan A, Schloithe AC, Hutton J, Yeoh EK, Fraser R, Dinning PG, Wattchow D. Pudendal nerve injury in men with fecal incontinence after radiotherapy for prostate cancer. Acta Oncol 2015; 54:882-8. [PMID: 25734401 DOI: 10.3109/0284186x.2015.1010693] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND The precise etiology of fecal incontinence (FI), which occurs frequently following external beam radiotherapy (EBRT) for prostate carcinoma is unknown. It is possibly related to pelvic nerve injury. The aim of this study was to assess the incidence of pudendal nerve dysfunction in men with FI after EBRT for prostate cancer compared to men with FI but no history of EBRT. MATERIAL AND METHODS Data were evaluated from 74 men with intact anal sphincters on endo-anal ultrasound (17 post-EBRT) who had been investigated for FI at a tertiary center. Wexner incontinence scores, pudendal nerve function, anorectal manometry, and rectal sensitivity were compared between the two patient groups. RESULTS Post-radiotherapy patients were older (77±6 vs. 62±17 years, p<0.005) and had worse incontinence than those with no history of radiotherapy (Wexner score; 13±3 vs. 8±4; p<0.005). Bilateral pudendal nerve terminal motor latency (PNTML) was abnormal in 87% of radiotherapy versus 22% of non-radiotherapy patients (p<0.001) and the significant difference persisted even after correction for age differences. Anal sphincter pressures and rectal sensitivity for both groups were similar. CONCLUSION There is a markedly higher incidence of pudendal nerve dysfunction in men with FI after EBRT for prostate cancer compared with men with FI from other etiologies. The increased severity of incontinence in radiotherapy patients is not matched by alterations in either anal sphincter pressures or rectal sensitivity compared to FI in non-ERBT patients.
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Affiliation(s)
- Arun Loganathan
- Department of Surgery, Flinders Medical Centre , Adelaide, South Australia , Australia
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