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Assmann SL, Mulders E, Kimman ML, Keszthelyi D, Breukink SO. Toward a core outcome set for faecal incontinence-A systematic review of outcomes reported in the literature. Colorectal Dis 2024. [PMID: 38923161 DOI: 10.1111/codi.17075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/25/2024] [Accepted: 05/27/2024] [Indexed: 06/28/2024]
Abstract
AIM Faecal incontinence (FI) is a prevalent issue which can have a detrimental impact on the patient's quality of life. Current international guidelines lack strong treatment recommendations due to few studies in the field, in combination with the heterogeneity in outcome reporting. To address this, a core outcome set (COS) is proposed to standardize outcome reporting in FI studies, facilitating meta-analyses and enhancing therapeutic recommendations. Through several steps outlined by COMET 'what' to measure will be determined prior to determining 'how' to measure these outcomes. This systematic review aims to identify 'what' outcomes have been used in FI intervention studies so far in adult patients as a starting phase for the development of a future COS for FI. METHOD Medline, Embase and the Cochrane library were searched to identify all outcomes reported in comparative effectiveness trials assessing one or more treatment option in adult patients suffering from FI. The outcomes were categorized according to the Core Outcome Measurement in Effectiveness Trials (COMET) taxonomy to standardize outcome terminology, assess completeness, and inform subsequent steps in COS development. RESULTS A total of 109 studies were included, which revealed 51 unique outcomes classified into 38 domains within four core areas. On average four outcomes were reported per study (range 1-11). The most commonly reported outcomes were "severity of FI" (83%), "quality of life" (64%), "number of FI episodes" (40%), "anorectal motor function" (39%), and "frequency of bowel movements" (16%). CONCLUSION This systematic review offers an overview of outcomes reported in FI studies, highlighting the heterogeneity between studies. This heterogeneity emphasizes the need for standardizing outcome reporting which can be established through the creation of a COS.
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Affiliation(s)
- Sadé L Assmann
- Department of Surgery and Colorectal Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Gastroenterology-Hepatology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Research Institute of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Evy Mulders
- Research Institute of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Merel L Kimman
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Daniel Keszthelyi
- Department of Gastroenterology-Hepatology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Research Institute of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Stephanie O Breukink
- Department of Surgery and Colorectal Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
- Research Institute of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
- Research Institute for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
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Meyer I, Iriondo-Perez J, Dyer KY, Sung V, Ackenbom MF, Florian-Rodriguez M, Kim E, Mazloomdoost D, Carper B, Gantz MG. Correlation Between Mobile-Application Electronic Bowel Diary and Validated Questionnaires in Women with Fecal Incontinence. Int Urogynecol J 2024; 35:545-551. [PMID: 38206340 PMCID: PMC11023758 DOI: 10.1007/s00192-023-05711-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/28/2023] [Indexed: 01/12/2024]
Abstract
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.
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Affiliation(s)
- Isuzu Meyer
- Department of Obstetrics and Gynecology, Division of Urogynecology and Pelvic Reconstructive Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
| | | | | | - Vivian Sung
- Alpert Medical School of Brown University, University/Women & Infants Hospital, Providence, RI, USA
| | - Mary F Ackenbom
- Magee-Womens Research Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Edward Kim
- Department of Obstetrics & Gynecology, Division of Urogynecology, University of Pennsylvania, Philadelphia, PA, USA
| | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | | | - Marie G Gantz
- RTI International, Research for the NICHD Pelvic Floor Disorders Network, Triangle Park, NC, USA
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Remes-Troche JM, Coss-Adame E, García-Zermeño KR, Gómez-Escudero O, Amieva-Balmori M, Gómez-Castaños PC, Charúa-Guindic L, Icaza-Chávez ME, López-Colombo A, Morel-Cerda EC, Pérez Y López N, Rodríguez-Leal MC, Salgado-Nesme N, Sánchez-Avila MT, Valdovinos-García LR, Vergara-Fernández O, Villar-Chávez AS. The Mexican consensus on fecal incontinence. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2023; 88:404-428. [PMID: 38097437 DOI: 10.1016/j.rgmxen.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 08/08/2023] [Indexed: 01/01/2024]
Abstract
Fecal incontinence is the involuntary passage or the incapacity to control the release of fecal matter through the anus. It is a condition that significantly impairs quality of life in those that suffer from it, given that it affects body image, self-esteem, and interferes with everyday activities, in turn, favoring social isolation. There are no guidelines or consensus in Mexico on the topic, and so the Asociación Mexicana de Gastroenterología brought together a multidisciplinary group (gastroenterologists, neurogastroenterologists, and surgeons) to carry out the «Mexican consensus on fecal incontinence» and establish useful recommendations for the medical community. The present document presents the formulated recommendations in 35 statements. Fecal incontinence is known to be a frequent entity whose incidence increases as individuals age, but one that is under-recognized. The pathophysiology of incontinence is complex and multifactorial, and in most cases, there is more than one associated risk factor. Even though there is no diagnostic gold standard, the combination of tests that evaluate structure (endoanal ultrasound) and function (anorectal manometry) should be recommended in all cases. Treatment should also be multidisciplinary and general measures and drugs (lidamidine, loperamide) are recommended, as well as non-pharmacologic interventions, such as biofeedback therapy, in selected cases. Likewise, surgical treatment should be offered to selected patients and performed by experts.
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Affiliation(s)
- J M Remes-Troche
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Mexico.
| | - E Coss-Adame
- Departamento de Gastroenterología y Laboratorio de Motilidad Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Mexico City, Mexico
| | - K R García-Zermeño
- Gastroenterología y Motilidad Digestiva, CIGMA, Boca del Río, Veracruz, Mexico
| | - O Gómez-Escudero
- Clínica de Gastroenterología, Endoscopía Digestiva y Motilidad Gastrointestinal, Hospital Ángeles de Puebla, Puebla, Mexico
| | - M Amieva-Balmori
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Mexico
| | - P C Gómez-Castaños
- Centro de Investigación y Docencia en Ciencias de la Salud, Universidad Autónoma de Sinaloa, Culiacán, Sinaloa, Mexico
| | - L Charúa-Guindic
- Práctica privada, Coloproctología del Hospital Ángeles Lomas, Mexico City, Mexico
| | - M E Icaza-Chávez
- Hospital Christus Muguerza Faro del Mayab, Mérida, Yucatán, Mexico
| | - A López-Colombo
- UMAE Hospital de Especialidades, Centro Médico Nacional Manuel Ávila Camacho, IMSS Puebla, Puebla, Mexico
| | - E C Morel-Cerda
- Laboratorio de Motilidad Gastrointestinal, Hospital Civil Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | | | - M C Rodríguez-Leal
- Hospital Ángeles Valle Oriente, IMSS UMAE 25, Monterrey, Nuevo León, Mexico
| | - N Salgado-Nesme
- Departamento de Cirugía, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Mexico City,Mexico
| | - M T Sánchez-Avila
- Escuela de Medicina y Ciencias de la Salud, Tecnológico de Monterrey, Monterrey, Nuevo León, Mexico
| | - L R Valdovinos-García
- Laboratorio de Motilidad Gastrointestinal Fundación Clínica Médica Sur, Mexico City, Mexico
| | - O Vergara-Fernández
- Departamento de Cirugía Colorrectal, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, Mexico
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Frudinger A, Gauruder-Burmester A, Graf W, Lehmann JP, Gunnarsson U, Mihov M, Ihnát P, Kosorok P, Orhalmi J, Slauf P, Emmanuel A, Hristov V, Jungwirthova A, Lehur PA, Müller A, Amort M, Marksteiner R, Thurner M. Skeletal Muscle-Derived Cell Implantation for the Treatment of Fecal Incontinence: A Randomized, Placebo-Controlled Study. Clin Gastroenterol Hepatol 2023; 21:476-486.e8. [PMID: 35961517 DOI: 10.1016/j.cgh.2022.07.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 07/08/2022] [Accepted: 07/25/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Fecal incontinence (FI) improvement following injection of autologous skeletal muscle-derived cells has been previously suggested. This study aimed to test the efficacy and safety of said cells through a multicenter, placebo-controlled study, to determine an appropriate cell dose, and to delineate the target patient population that can most benefit from cell therapy. METHODS Patients experiencing FI for at least 6 months were randomized to receive a cell-free medium or low or high dose of cells. All patients received pelvic floor electrical stimulation before and after treatment. Incontinence episode frequency (IEF), FI quality of life, FI burden assessed on a visual analog scale, Wexner score, and parameters reflecting anorectal physiological function were all assessed for up to 12 months. RESULTS Cell therapy improved IEF, FI quality of life, and FI burden, reaching a preset level of statistical significance in IEF change compared with the control treatment. Post hoc exploratory analyses indicated that patients with limited FI duration and high IEF at baseline are most responsive to cells. Effects prevailed or increased in the high cell count group from 6 to 12 months but plateaued or diminished in the low cell count and control groups. Most physiological parameters remained unaltered. No unexpected adverse events were observed. CONCLUSIONS Injection of a high dose of autologous skeletal muscle-derived cells followed by electrical stimulation significantly improved FI, particularly in patients with limited FI duration and high IEF at baseline, and could become a valuable tool for treatment of FI, subject to confirmatory phase 3 trial(s). (ClinicalTrialRegister.eu; EudraCT Number: 2010-021463-32).
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Affiliation(s)
- Andrea Frudinger
- Department of Obstetrics and Gynaecology, Medical University of Graz, Graz, Austria.
| | | | - Wilhelm Graf
- Department of Surgery, Akademiska Sjukhuset, Uppsala, Sweden
| | | | - Ulf Gunnarsson
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Minko Mihov
- Medical Center Unimed EOOD, Sevlievo, Bulgaria
| | - Peter Ihnát
- Department of Surgical Studies, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Pavle Kosorok
- Department of Proctology, Iatros Medical Centre, Ljubljana, Slovenia
| | - Julius Orhalmi
- Department of Surgery, University Hospital Hradec Kralove, Faculty of Medicine in Hradec Kralove, Charles University, Prague, Czech Republic
| | - Petr Slauf
- Surgical Clinic 1, Faculty of Medicine, University Hospital Bulovka, Charles University, Prague, Czech Republic
| | - Anton Emmanuel
- Gastrointestinal Physiology Unit, University College Hospital, London, United Kingdom
| | | | - Anna Jungwirthova
- Department of Gastroenterology, St. Anna Clinic, Prague, Czech Republic
| | - Paul-Antoine Lehur
- Clinique de Chirurgie Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, University Hospital of Nantes, Nantes, France
| | - Andreas Müller
- GastroZentrum Hirslanden, Klinik Hirslanden, Zürich, Switzerland
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Bharucha AE, Knowles CH, Mack I, Malcolm A, Oblizajek N, Rao S, Scott SM, Shin A, Enck P. Faecal incontinence in adults. Nat Rev Dis Primers 2022; 8:53. [PMID: 35948559 DOI: 10.1038/s41572-022-00381-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/29/2022] [Indexed: 11/09/2022]
Abstract
Faecal incontinence, which is defined by the unintentional loss of solid or liquid stool, has a worldwide prevalence of ≤7% in community-dwelling adults and can markedly impair quality of life. Nonetheless, many patients might not volunteer the symptom owing to embarrassment. Bowel disturbances, particularly diarrhoea, anal sphincter trauma (obstetrical injury or previous surgery), rectal urgency and burden of chronic illness are the main risk factors for faecal incontinence; others include neurological disorders, inflammatory bowel disease and pelvic floor anatomical disturbances. Faecal incontinence is classified by its type (urge, passive or combined), aetiology (anorectal disturbance, bowel symptoms or both) and severity, which is derived from the frequency, volume, consistency and nature (urge or passive) of stool leakage. Guided by the clinical features, diagnostic tests and therapies are implemented stepwise. When simple measures (for example, bowel modifiers such as fibre supplements, laxatives and anti-diarrhoeal agents) fail, anorectal manometry and other tests (endoanal imaging, defecography, rectal compliance and sensation, and anal neurophysiological tests) are performed as necessary. Non-surgical options (diet and lifestyle modification, behavioural measures, including biofeedback therapy, pharmacotherapy for constipation or diarrhoea, and anal or vaginal barrier devices) are often effective, especially in patients with mild faecal incontinence. Thereafter, perianal bulking agents, sacral neuromodulation and other surgeries may be considered when necessary.
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Affiliation(s)
- Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
| | - Charles H Knowles
- Blizard Institute, Centre for Neuroscience, Surgery & Trauma, Queen Mary University of London, London, UK
| | - Isabelle Mack
- University Hospital, Department of Psychosomatic Medicine, Tübingen, Germany
| | - Allison Malcolm
- Department of Gastroenterology, Royal North Shore Hospital and University of Sydney, Sydney, New South Wales, Australia
| | - Nicholas Oblizajek
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Satish Rao
- Department of Gastroenterology, University of Georgia, Augusta, GA, USA
| | - S Mark Scott
- Blizard Institute, Centre for Neuroscience, Surgery & Trauma, Queen Mary University of London, London, UK
| | - Andrea Shin
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, IN, USA
| | - Paul Enck
- University Hospital, Department of Psychosomatic Medicine, Tübingen, Germany.
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Asnong A, D’Hoore A, Wolthuis A, Van Molhem Y, Van Geluwe B, Devoogdt N, De Groef A, De Vrieze T, Dams L, Geraerts I. Is evaluation by questionnaires sufficient to cover all aspects of bowel symptoms in rectal cancer patients after low anterior resection? Colorectal Dis 2022; 24:611-620. [PMID: 35040548 PMCID: PMC9306656 DOI: 10.1111/codi.16055] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 01/05/2022] [Accepted: 01/08/2022] [Indexed: 01/01/2023]
Abstract
AIM The aim of the study was to investigate whether bowel symptoms related to low anterior resection for rectal cancer can be sufficiently well evaluated by the Low Anterior Resection Syndrome (LARS) questionnaire score or the ColoRectal Functional Outcome (COREFO) questionnaire compared with a stool diary. METHOD All patients underwent low anterior resection for rectal cancer. They were asked to fill out a stool diary, the LARS questionnaire and the COREFO questionnaire, at 1, 4, 6 and 12 months after low anterior resection or stoma closure. The main outcome measure was the amount of association (calculated by means of canonical correlation analysis) between items on anal incontinence for faeces, frequency of bowel movements, clustering of bowel movements, urgency and soiling. RESULTS Ninety-five patients were included. Items on anal incontinence for faeces and frequency of bowel movements were significantly correlated between the LARS questionnaire or the COREFO questionnaire, versus the stool diary, respectively. Items on soiling were significantly correlated between the COREFO questionnaire and the stool diary. CONCLUSION Although the LARS questionnaire and the COREFO questionnaire are reliable and valid for measuring low anterior resection syndrome after rectal cancer, our results show that there are no strong associations with the stool diary. Therefore, we can conclude that there is additional clinical information to be obtained from the stool diary. In order to evaluate all aspects of low anterior resection syndrome, we suggest the addition of a stool diary or a combination of different measurement methods during patient follow-up.
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Affiliation(s)
- Anne Asnong
- Department of Rehabilitation SciencesKU Leuven – University of LeuvenLeuvenBelgium
| | - André D’Hoore
- Department of Abdominal SurgeryUniversity Hospitals GasthuisbergLeuvenBelgium,KU Leuven – University of LeuvenLeuvenBelgium
| | - Albert Wolthuis
- Department of Abdominal SurgeryUniversity Hospitals GasthuisbergLeuvenBelgium,KU Leuven – University of LeuvenLeuvenBelgium
| | - Yves Van Molhem
- Department of Abdominal SurgeryOLV HospitalsAalst/Asse/NinoveBelgium
| | - Bart Van Geluwe
- Department of Abdominal SurgeryUniversity Hospitals GasthuisbergLeuvenBelgium
| | - Nele Devoogdt
- Department of Rehabilitation SciencesKU Leuven – University of LeuvenLeuvenBelgium,Center for LymphedemaUniversity Hospitals LeuvenLeuvenBelgium
| | - An De Groef
- Department of Rehabilitation SciencesKU Leuven – University of LeuvenLeuvenBelgium,Department of Rehabilitation SciencesUniversity of AntwerpAntwerpBelgium,International Research Group Pain in MotionBrusselsBelgium
| | - Tessa De Vrieze
- Department of Rehabilitation SciencesKU Leuven – University of LeuvenLeuvenBelgium,Department of Rehabilitation Sciences and PhysiotherapyMOVANTUniversity of AntwerpAntwerpBelgium
| | - Lore Dams
- Department of Rehabilitation SciencesKU Leuven – University of LeuvenLeuvenBelgium,International Research Group Pain in MotionBrusselsBelgium,Department of Rehabilitation Sciences and PhysiotherapyMOVANTUniversity of AntwerpAntwerpBelgium
| | - Inge Geraerts
- Department of Rehabilitation SciencesKU Leuven – University of LeuvenLeuvenBelgium
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Futaba K, Chen SC, Leung WW, Wong C, Mak T, Ng S, Gregersen H. Fecobionics Evaluation of Biofeedback Therapy in Patients With Fecal Incontinence. Clin Transl Gastroenterol 2022; 13:e00491. [PMID: 35363631 PMCID: PMC9132520 DOI: 10.14309/ctg.0000000000000491] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 03/21/2022] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Biofeedback therapy (BFT) is a well-known treatment for functional anorectal disorders. The effect of BFT was monitored in fecal incontinence (FI) patients with the Fecobionics test and with the conventional technologies, anorectal manometry (ARM) and balloon expulsion test (BET). METHODS Studies were performed in 12 patients before and after 8 weeks of biofeedback training. The Fecal Incontinence Severity Index (FISI) score was obtained. Anal resting and squeeze pressures were measured before the bag was distended in the rectum until urge to defecate. Pressure recordings were made during Fecobionics evacuation. RESULTS BFT resulted in 24% reduction in FISI scores (P < 0.01). Seven patients were characterized as responders. Anal pressures, the urge-to-defecate volume, and defecatory parameters did not change significantly during BFT. For ARM-BET, the maximum anal squeeze pressure, the urge-to-defecate volume, and the expulsion time were lower after BFT compared with those before BFT (P < 0.05). For Fecobionics, the change in urge volume (r = 0.74, P < 0.05) and the change in defecation index (r = 0.79, P < 0.01) were associated with the change in FISI score. None of the ARM-BET parameters were associated with the change in FISI score. It was studied whether any pre-BFT data could predict treatment success. The Fecobionics expulsion duration and the defecation index predicted the outcome (P < 0.05). The defecation index had a sensitivity of 100% and a specificity of 72%. None of the ARM-BET parameters predicted the outcome (all P > 0.2). DISCUSSION Fecobionics was used as a tool to monitor the effect of BFT and proved better than conventional technologies for monitoring and predicting the outcome in the FISI score.
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Affiliation(s)
- Kaori Futaba
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Ssu-Chi Chen
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Wing Wa Leung
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Cherry Wong
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Tony Mak
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Simon Ng
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Hans Gregersen
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
- California Medical Innovations Institute, San Diego, California, USA
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Livovsky DM, Koslowsky B, Goldin E, Lysy J. External kinesiology tape for improvement in fecal incontinence symptom bother in women: a pilot study. Int Urogynecol J 2022; 33:2859-2868. [PMID: 35039916 DOI: 10.1007/s00192-021-05050-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 11/14/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Fecal incontinence is a debilitating condition with a devastating impact on quality of life. Using a commercially available kinesiology band we developed an anal tape to be applied to the anus with the aim to determine its impact on symptom bother and quality of life. METHODS Four-week prospective, self-controlled, pilot study of patients with FI. The primary outcome was improvement in any of the four domains (lifestyle, coping/behavior, depression/self-perception, embarrassment) evaluated by the "Fecal Incontinence Quality of Life Scale." Secondary outcomes included improvement in frequency of incontinence events and safety. Days 0-14 served as control period and days 15-28 as study period. Patients were asked to rate their satisfaction and willingness to use the device in the future using a 10-cm continuous visual analog scale. RESULTS Twenty patients completed the study. Median age was 64 years; all patients were females. Significant improvements were observed in all domains of the Fecal Incontinence Quality of Life Scale from baseline to day 28 (p < 0.001 for all) and in three of four domains between day 15 and 28 (p < 0.04) but not between days 1 and 14. Five patients (25%) had a ≥ 50% improvement in incontinence events. Patients reported satisfaction and willingness to use the anal tape in the future. Other than mild difficulty to remove the anal tape, no adverse events were reported. CONCLUSIONS In this small pilot study, the use of the anal tape was safe and effective. The primary outcome of significant improvement in quality of life was achieved ( ClinicalTrials.gov ID:NCT02989545). PUBLIC TRIAL REGISTRY ClinicalTrials.gov identifier NCT02989545. https://clinicaltrials.gov/ct2/show/NCT02989545.
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Affiliation(s)
- Dan M Livovsky
- Digestive Diseases Institute, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
- The Neurogastroenterology and Pelvic Floor Unit, Digestive Diseases Institute, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Israel, 12 Baiyt St., Jerusalem, Israel.
| | - Benjamin Koslowsky
- Digestive Diseases Institute, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Eran Goldin
- Digestive Diseases Institute, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Joseph Lysy
- Digestive Diseases Institute, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- The Neurogastroenterology and Pelvic Floor Unit, Digestive Diseases Institute, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Israel, 12 Baiyt St., Jerusalem, Israel
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9
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Xiang X, Sharma A, Patcharatrakul T, Yan Y, Karunaratne T, Parr R, Ayyala DN, Hall P, Rao SSC. Randomized controlled trial of home biofeedback therapy versus office biofeedback therapy for fecal incontinence. Neurogastroenterol Motil 2021; 33:e14168. [PMID: 34051120 DOI: 10.1111/nmo.14168] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 03/04/2021] [Accepted: 04/15/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Biofeedback therapy is useful for treatment of fecal incontinence (FI), but is not widely available and labor intensive. We investigated if home biofeedback therapy (HBT) is non-inferior to office biofeedback therapy (OBT). METHODS Patients with FI (≥1 episode/week) were randomized to HBT or OBT for 6 weeks. HBT was performed daily using novel device that provided resistance training and electrical stimulation with voice-guided instructions. OBT consisted of six weekly sessions. Both methods involved anal strength, endurance, and coordination training. Primary outcome was change in weekly FI episodes. FI improvement was assessed with stool diaries, validated instruments (FISI, FISS, and ICIQ-B), and anorectal manometry using intention-to-treat analysis. KEY RESULTS Thirty (F/M = 26/4) FI patients (20 in HBT, 10 in OBT) participated. Weekly FI episodes decreased significantly after HBT (Δ ± 95% confidence interval: 4.7 ± 1.8, compared with baseline, p = 0.003) and OBT (3.7 ± 1.6, p = 0.0003) and HBT was non-inferior to OBT (p = 0.2). The FISI and FISS scores improved significantly in HBT group (p < 0.02). Bowel pattern, bowel control, and quality of life (QOL) domains (ICIQ-B) improved significantly in HBT arm (p < 0.023). Resting and maximum squeeze sphincter pressures significantly improved in both HBT and OBT groups and sustained squeeze pressure in HBT, without group differences. CONCLUSIONS & INFERENCES Home biofeedback therapy is non-inferior to OBT for FI treatment. Home biofeedback is safe, effective, improves QOL, and through increased access could facilitate improved management of FI.
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Affiliation(s)
- Xuelian Xiang
- Division of Gastroenterology & Hepatology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Amol Sharma
- Division of Gastroenterology & Hepatology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Tanisa Patcharatrakul
- Division of Gastroenterology & Hepatology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Yun Yan
- Division of Gastroenterology & Hepatology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Tennekoon Karunaratne
- Division of Gastroenterology & Hepatology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Rachel Parr
- Division of Gastroenterology & Hepatology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Deepak Nag Ayyala
- Department of Population Health Sciences, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Patricia Hall
- Department of Population Health Sciences, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Satish S C Rao
- Division of Gastroenterology & Hepatology, Medical College of Georgia, Augusta University, Augusta, GA, USA
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Leo CA, Thomas GP, Hodgkinson JD, Leeuwenburgh M, Bradshaw E, Warusavitarne J, Murphy J, Vaizey CJ. Randomized Pilot Study: Anal Inserts Versus Percutaneous Tibial Nerve Stimulation in Patients With Fecal Incontinence. Dis Colon Rectum 2021; 64:466-474. [PMID: 33399411 DOI: 10.1097/dcr.0000000000001913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Anal inserts and percutaneous tibial nerve stimulation may be offered to those with fecal incontinence in whom other conservative treatments have failed. OBJECTIVE We aimed to compare anal inserts and percutaneous tibial nerve stimulation. DESIGN This was an investigator-blinded randomized pilot study. SETTINGS The study was conducted at a large tertiary care hospital. PATIENTS Adult patients with passive or mixed fecal incontinence were recruited. INTERVENTIONS Patients were randomly assigned to receive either the anal inserts or weekly percutaneous tibial nerve stimulation for a period of 3 months. MAIN OUTCOME MEASURES The primary end point was a 50% reduction of episodes of fecal incontinence per week as calculated by a prospectively completed 2-week bowel diary. Secondary end points were St Mark's incontinence score, International Consultation on Incontinence Questionnaire-Bowel scores (for bowel pattern, bowel control, and quality of life), use of antidiarrheal agents, estimates of comfort and acceptability. RESULTS Fifty patients were recruited: 25 were randomly assigned to anal inserts and 25 were randomly assigned to percutaneous tibial nerve stimulation. All completed treatment. A significant improvement of scores in the 2-week bowel diary, the St Mark's scores and the International Consultation on Incontinence Questionnaire-Bowel scores, was seen in both groups after 3 months of treatment. A reduction of ≥50% fecal incontinence episodes was reached by 76% (n = 19/25) by the anal insert group, compared with 48% (n = 12/25) of those in the percutaneous tibial nerve stimulation group (p = 0.04). The St Mark's fecal incontinence scores and the International Consultation on Incontinence Questionnaire-Bowel scores for bowel pattern, bowel control, and quality of life (p = 0.01) suggest similar improvement for each group. LIMITATIONS A realistic sample size calculation could not be performed because of the paucity of objective prospective studies assessing the effect of the insert device and percutaneous tibial nerve stimulation. CONCLUSIONS Both anal insert and percutaneous tibial nerve stimulation improved the symptoms of fecal incontinence after 3 months of treatment. The insert device appeared to be more effective than percutaneous tibial nerve stimulation. Larger studies are needed to investigate this further. See Video Abstract at http://links.lww.com/DCR/B460. TRIAL REGISTRATION NUMBER Clinicaltrials.gov No. NCT04273009. ESTUDIO PILOTO ALEATORIZADO DE INSERCIONES ANALES CONTRA LA ESTIMULACIN PERCUTNEA DEL NERVIO TIBIAL EN PACIENTES CON INCONTINENCIA FECAL ANTECEDENTES:Las inserciones anales y la estimulación percutánea del nervio tibial (PTNS) se pueden ofrecer a las personas con incontinencia fecal que han fallado en otros tratamientos conservadores.OBJETIVO:Nuestro objetivo fue comparar inserciones anales y estimulación percutánea del nervio tibial.DISEÑO:Este fue un estudio piloto aleatorio ciego para investigadores.AJUSTE:El estudio se realizó en un hospital de atención terciaria.PACIENTES:Se reclutaron pacientes adultos con incontinencia fecal pasiva o mixta.INTERVENCIONES:Los pacientes fueron asignados al azar para recibir inserciones anales o estimulación del nervio tibial percutáneo semanal durante un período de tres meses.PRINCIPALES MEDIDAS DE RESULTADO:El principal resultado fue una reducción del 50% de los episodios de incontinencia fecal por semana, según lo calculado mediante un diario intestinal de dos semanas completado de forma prospectiva. Los criterios de valoración secundarios fueron la puntuación de incontinencia de St Mark, las puntuaciones del ICIQ-B (para patrón intestinal, control intestinal y calidad de vida), uso de agentes antidiarreicos, estimaciones de comodidad y aceptabilidad.RESULTADOS:Se reclutaron 50 pacientes: 25 fueron asignados al azar a inserciones anales y 25 a PTNS. Todo el tratamiento completado. Se observó una mejora significativa de las puntuaciones en el diario intestinal de dos semanas, la puntuación de St Mark y la puntuación del ICIQ-B en ambos grupos después de 3 meses de tratamiento. Se alcanzó una reducción de ≥ 50% de los episodios de incontinencia fecal en un 76% (n = 19/25) en el grupo de inserción anal, en comparación con el 48% (n = 12/25) de los del grupo de estimulación percutánea del nervio tibial (p = 0,04). Las puntuaciones de incontinencia fecal de St Mark, las puntuaciones del ICIQ-B para el patrón intestinal, el control intestinal y la calidad de vida (p = 0,01) sugieren una mejora similar para cada grupo.LIMITACIONES:No se pudo realizar un cálculo realista del tamaño de la muestra debido a la escasez de estudios prospectivos objetivos que evaluaran el efecto del dispositivo de inserción y la estimulación percutánea del nervio tibial.CONCLUSIONES:Tanto la inserción anal como la estimulación percutánea del nervio tibial mejoraron los síntomas de incontinencia fecal después de 3 meses de tratamiento. El dispositivo de inserción parecia ser más efectivo que la estimulación percutánea del nervio tibial. Se necesitan estudios más amplios para investigar esto más a fondo. Consulte Video Resumen en http://links.lww.com/DCR/B460.NÚMERO DE REGISTRO DE PRUEBA:Clinicaltrials.gov No. NCT04273009.
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Affiliation(s)
- Cosimo Alex Leo
- Department of Surgery, St Mark's Hospital and Academic Institute, London, United Kingdom
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
- Department of Surgery, The Royal London Hospital, London, United Kingdom
| | - Gregory P Thomas
- Department of Surgery, St Mark's Hospital and Academic Institute, London, United Kingdom
| | - Jonathan D Hodgkinson
- Department of Surgery, St Mark's Hospital and Academic Institute, London, United Kingdom
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Marjolein Leeuwenburgh
- Department of Surgery, The Royal London Hospital, London, United Kingdom
- Department of Surgery, Haaglanden Medisch Centrum, Den Haag, The Netherlands
| | - Ellie Bradshaw
- Department of Surgery, St Mark's Hospital and Academic Institute, London, United Kingdom
| | - Janindra Warusavitarne
- Department of Surgery, St Mark's Hospital and Academic Institute, London, United Kingdom
| | - Jamie Murphy
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Carolynne J Vaizey
- Department of Surgery, St Mark's Hospital and Academic Institute, London, United Kingdom
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
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Assmann S, Keszthelyi D, Kleijnen J, Kimman M, Anastasiou F, Bradshaw E, Carrington E, Chiarioni G, Maeda Y, Muris J, Pohl D, Rydningen M, Vaizey C, Breukink S. The development of a faecal incontinence core outcome set: an international Delphi study protocol. Int J Colorectal Dis 2021; 36:617-622. [PMID: 33532899 PMCID: PMC7895769 DOI: 10.1007/s00384-021-03865-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/26/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Faecal incontinence (FI) is estimated to affect around 7.7% of people. There is a lack of uniformity in outcome definitions, measurement and reporting in FI studies. Until now, there is no general consensus on which outcomes should be assessed and reported in FI research. This complicates comparison between studies and evidence synthesis, potentially leading to recommendations not evidence-based enough to guide physicians in selecting an FI therapy. A solution for this lack of uniformity in reporting of outcomes is the development of a Core Outcome Set (COS) for FI. This paper describes the protocol for the development of a European COS for FI. METHODS Patient interviews and a systematic review of the literature will be performed to identify patient-, physician- and researcher-oriented outcomes. The outcomes will be categorised using the COMET taxonomy and put forward to a group of patients, physicians (i.e. colorectal surgeons, gastroenterologists and general practitioners) and researchers in a Delphi consensus exercise. This exercise will consist of up to three web-based rounds in which participants will prioritise and condense the list of outcomes, which is expected to result in consensus. A consensus meeting with participants from all stakeholder groups will take place to reach a final agreement on the COS. DISCUSSION This study protocol describes the development of a European COS to improve reliability and consistency of outcome reporting in FI studies, thereby improving evidence synthesis and patient care. TRIAL REGISTRATION This project has been registered in the COMET database on the 1st of April 2020, available at http://www.comet-initiative.org/Studies/Details/1554 . The systematic review has been registered on the PROSPERO database on the 31st of August 2020, available at https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=202020&VersionID=1381336 .
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Affiliation(s)
- Sadé Assmann
- Department of Surgery and Colorectal Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands.
- Division of Gastroenterology-Hepatology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands.
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands.
| | - Daniel Keszthelyi
- Division of Gastroenterology-Hepatology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
| | - Jos Kleijnen
- School for Oncology and Developmental Biology (GROW), Maastricht University, Maastricht, The Netherlands
| | - Merel Kimman
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Foteini Anastasiou
- 4rth TOMY - Academic Primary Care Unit Clinic of Social and Family Medicine, University of Crete, Heraklion, Greece
| | - Elissa Bradshaw
- Community Gastroenterology Specialist Nurse, Royal Free Hospital, London, England
| | - Emma Carrington
- Surgical Professorial Unit, Department of Colorectal Surgery, St Vincent's University Hospital, Dublin, Ireland
| | - Giuseppe Chiarioni
- Division of Gastroenterology of the University of Verona, AOUI Verona, Verona, Italy
- Center for Functional GI and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Yasuko Maeda
- Department of Surgery and Colorectal Surgery, Western General Hospital, Edinburgh, UK
| | - Jean Muris
- Department of General Practice, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Daniel Pohl
- Department of Gastroenterology and Hepatology, University Hospital of Zurich, Zurich, Switzerland
| | - Mona Rydningen
- Department of Gastrointestinal Surgery, University Hospital of North Norway, Tromsø, Norway
- Norwegian National Advisory Unit on Incontinence and Pelvic Floor Health, Tromsø, Norway
| | | | - Stephanie Breukink
- Department of Surgery and Colorectal Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
- School for Oncology and Developmental Biology (GROW), Maastricht University, Maastricht, The Netherlands
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12
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Mazor Y, Prott G, Jones M, Ejova A, Kellow J, Malcom A. Factors Associated With Response to Anorectal Biofeedback Therapy in Patients With Fecal Incontinence. Clin Gastroenterol Hepatol 2021; 19:492-502.e5. [PMID: 32251788 DOI: 10.1016/j.cgh.2020.03.050] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 03/06/2020] [Accepted: 03/22/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Anorectal biofeedback (BF) is commonly used to treat patients with fecal incontinence (FI), but demand usually exceeds availability. It is therefore important to identify patients most likely to respond to BF treatment. We aimed to identify pre-treatment clinical or physiologic factors that might be used to predict completion and success of BF in women with FI. METHODS We analyzed data from 400 women with FI (mean age, 61 ± 14 y) undergoing instrumental BF in a tertiary care setting from 2003 through 2016. All patients completed questionnaires before BF, including Rome and the hospital anxiety and depression scale questionnaires. Histories of medication use, surgery, medical conditions, and bowel pattern were recorded, urge was assessed, and patients kept stool diaries. Before and after treatment (6 weekly sessions with a gastroenterologist-supervised nurse specialist, 4 involving instrumented anorectal biofeedback), patients were examined by a physician and fecal incontinence severity index and visual analogue scale scores were recorded. The main outcome measure was response to therapy, defined as improvement of 50% or more in weekly FI episodes at the end of BF compared with before BF. RESULTS The BF treatment was completed by 363 women (91%); of these, 62 had low baseline symptom frequency (no FI episodes in the 2 weeks before BF). Younger age was associated with failure to complete treatment. Of the 301 patients remaining, 202 patients (67%) had a response to therapy; among these women, urge FI was associated with response at end of BF, but not at follow up (6 months after therapy). Baseline severity of symptom scores and quality of life measures were associated with greater improvement in the same variable at the end of BF and after 6 months. Patients with low baseline symptom frequency improved in all secondary outcome measures, similar to patients with higher baseline symptom frequency. CONCLUSIONS In an analysis of 363 women with FI, approximately two-thirds had a response to BF treatment. Urge FI was the only baseline variable associated with response. Baseline severity of symptoms and quality of life measures were associated with greater improvement in the same variable, but not overall response. It is therefore a challenge to select treatment for patients with FI.
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Affiliation(s)
- Yoav Mazor
- Department of Gastroenterology, Royal North Shore Hospital, St Leonards, NSW; University of Sydney, Sydney, NSW.
| | - Gillian Prott
- Department of Gastroenterology, Royal North Shore Hospital, St Leonards, NSW
| | - Michael Jones
- Department of Psychology, Macquarie University, Sydney, NSW, Australia
| | - Anastasia Ejova
- Department of Psychology, Macquarie University, Sydney, NSW, Australia
| | - John Kellow
- Department of Gastroenterology, Royal North Shore Hospital, St Leonards, NSW; University of Sydney, Sydney, NSW
| | - Allison Malcom
- Department of Gastroenterology, Royal North Shore Hospital, St Leonards, NSW; University of Sydney, Sydney, NSW
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13
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Translumbosacral Neuromodulation Therapy for Fecal Incontinence: A Randomized Frequency Response Trial. Am J Gastroenterol 2021; 116:162-170. [PMID: 32740081 PMCID: PMC9455260 DOI: 10.14309/ajg.0000000000000766] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 05/21/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Treatments for fecal incontinence (FI) remain unsatisfactory because they do not remedy the underlying multifactorial dysfunction(s) including anorectal neuropathy. The aim of this study was to investigate the optimal dose frequency, clinical effects, and safety of a novel treatment, translumbosacral neuromodulation therapy (TNT), aimed at improving neuropathy. METHODS Patients with FI were randomized to receive 6 sessions of weekly TNT treatments consisting of 600 repetitive magnetic stimulations over each of 2 lumbar and 2 sacral sites with either 1, 5, or 15 Hz frequency. Stool diaries, FI severity indices, anorectal neurophysiology and sensorimotor function, and quality of life were compared. Primary outcome measure was the change in FI episodes/week. Responders were patients with ≥50% decrease in weekly FI episodes. RESULTS Thirty-three patients with FI participated. FI episodes decreased significantly (∆ ±95% confidence interval, 4.2 ± 2.8 (1 Hz); 2 ± 1.7 (5 Hz); 3.4 ± 2.5 (15 Hz); P < 0.02) in all 3 groups when compared with baseline. The 1 Hz group showed a significantly higher (P = 0.04) responder rate (91 ± 9.1%) when compared with the 5 Hz group (36 ± 18.2%) or 15 Hz (55 ± 18.2%); no difference was found between the 5 and 15 Hz groups (P = 0.667). Anal neuropathy, squeeze pressure, and rectal capacity improved significantly only in the 1 Hz (P < 0.05) group compared with baseline, but not in other groups. Quality of life domains improved significantly (P < 0.05) with 1 and 5 Hz groups. No device-related serious adverse events were noted. DISCUSSION TNT significantly improves FI symptoms in the short term, and the 1 Hz frequency was overall better than 5 and 15 Hz. Both anorectal neuropathy and physiology significantly improved, demonstrating mechanistic improvement. TNT is a promising, novel, safe, efficacious, and noninvasive treatment for FI (see Visual Abstract, Supplementary Digital Content 3, http://links.lww.com/AJG/B598).
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14
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Curtin B, Jimenez E, Rao SSC. Clinical Evaluation of a Patient With Symptoms of Colonic or Anorectal Motility Disorders. J Neurogastroenterol Motil 2020; 26:423-436. [PMID: 32989182 PMCID: PMC7547199 DOI: 10.5056/jnm20012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 08/11/2020] [Accepted: 08/16/2020] [Indexed: 12/13/2022] Open
Abstract
Constipation, irritable bowel syndrome, fecal incontinence, abdominal pain, and anorectal pain are problems that affect 40% of the population. They commonly present with overlapping symptoms indicating that their pathophysiology affects multiple segments of the gut as well as brain and gut interactions. Clinically, although some conditions are readily recognized, dyssynergic defecation, fecal incontinence, and anorectal pain are often missed or misdiagnosed. Consequently, the assessment of lower gastrointestinal symptoms in patients with suspected colonic or anorectal motility disorder(s) remains challenging for most clinicians. A detailed history, use of the Bristol stool form scale, prospective stool diaries, ideally through a phone App, digital rectal examination, and judicious use of complementary diagnostic tests are essential. Additionally, it is important to evaluate the impact of these problems on quality of life and psychosocial issues, because they are intricately linked with these disorders. The Rome IV diagnostic questionnaire for functional gastrointestinal disorders can provide additional information often missed during history taking. Here, we discuss a systematic approach for the clinical evaluation of patients with suspected lower gastrointestinal problems, grouped under 4 common diagnostic categories. We describe how to take a detailed history, perform meticulous digital rectal examination, and use validated tools to supplement clinical evaluation, including assessments of quality of life and scoring systems for disease severity and digital Apps. These tools could facilitate a comprehensive plan for clinical management including diagnostic tests, and translate the patients' complaints into definable, diagnostic categories.
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Affiliation(s)
- Bryan Curtin
- Division of Gastroenterology and Hepatology, Digestive Health Center, Augusta University, Medical College of Georgia, Augusta, GA, USA
| | - Enoe Jimenez
- Division of Gastroenterology and Hepatology, Digestive Health Center, Augusta University, Medical College of Georgia, Augusta, GA, USA
| | - Satish S C Rao
- Division of Gastroenterology and Hepatology, Digestive Health Center, Augusta University, Medical College of Georgia, Augusta, GA, USA
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Richter HE, Jelovsek JE, Iyer P, Rogers RG, Meyer I, Newman DK, Bradley MS, Harm-Ernandes I, Dyer KY, Wohlrab K, Mazloomdoost D, Gantz MG. Characteristics Associated With Clinically Important Treatment Responses in Women Undergoing Nonsurgical Therapy for Fecal Incontinence. Am J Gastroenterol 2020; 115:115-127. [PMID: 31895722 PMCID: PMC7197976 DOI: 10.14309/ajg.0000000000000482] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To identify baseline clinical and demographic characteristics associated with clinically important treatment responses in a randomized trial of nonsurgical therapies for fecal incontinence (FI). METHODS Women (N = 296) with FI were randomized to loperamide or placebo- and manometry-assisted biofeedback exercises or educational pamphlet in a 2 × 2 factorial design. Treatment response was defined in 3 ways from baseline to 24 weeks: minimal clinically important difference (MID) of -5 points in St. Mark's score, ≥50% reduction in FI episodes, and combined St. Mark's MID and ≥50% reduction FI episodes. Multivariable logistic regression models included baseline characteristics and treatment groups with and without controlling for drug and exercise adherence. RESULTS Treatment response defined by St. Mark's MID was associated with higher symptom severity (adjusted odds ratio [aOR] 1.20, 95% confidence interval [CI] 1.11-1.28) and being overweight vs normal/underweight (aOR 2.15, 95% CI 1.07-4.34); these predictors remained controlling for adherence. Fifty percent reduction in FI episodes was associated with the combined loperamide/biofeedback group compared with placebo/pamphlet (aOR 4.04, 95% CI 1.36-11.98), St. Mark's score in the placebo/pamphlet group (aOR 1.29, 95% CI 1.01-1.65), FI subtype of urge vs urge plus passive FI (aOR 2.39, 95% CI 1.09-5.25), and passive vs urge plus passive FI (aOR 3.26, 95% CI 1.48-7.17). Controlling for adherence, associations remained, except St. Mark's score. DISCUSSION Higher severity of FI symptoms, being overweight, drug adherence, FI subtype, and combined biofeedback and medication treatment were associated with clinically important treatment responses. This information may assist in counseling patients, regarding efficacy and expectations of nonsurgical treatments of FI.
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Affiliation(s)
- Holly E Richter
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - J E Jelovsek
- Department of Obstetrics and Gynecology, Cleveland Clinic, Cleveland, Ohio
| | - P Iyer
- RTI International, Research Triangle Park, North Carolina
| | - R G Rogers
- Dell Medical School, Department of Obstetrics and Gynecology, University of Texas at Austin, Austin, Texas
- Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque, New Mexico
| | - I Meyer
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - D K Newman
- Perelman School of Medicine, Department of Urology, University Pennsylvania, Philadelphia, Pennsylvania
| | - M S Bradley
- Department of Obstetrics and Gynecology, University of Pittsburgh, Magee-Women's Research Institute, Pittsburgh, Pennsylvania
| | - I Harm-Ernandes
- Department of Physical Therapy and Occupational Therapy, Duke University, Durham, North Carolina
| | - K Y Dyer
- Department of Obstetrics and Gynecology, Kaiser Permanente, San Diego, California
| | - K Wohlrab
- Department of Obstetrics and Gynecology, Brown University, Providence, Rhode Island
| | | | - M G Gantz
- RTI International, Research Triangle Park, North Carolina
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Mazor Y, Kellow JE, Prott GM, Jones MP, Malcolm A. Anorectal biofeedback: an effective therapy, but can we shorten the course to improve access to treatment? Therap Adv Gastroenterol 2019; 12:1756284819836072. [PMID: 30915166 PMCID: PMC6429655 DOI: 10.1177/1756284819836072] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 01/24/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Instrumented anorectal biofeedback (BF) improves symptoms and quality of life in patients with faecal incontinence and defecation disorder-associated chronic constipation. However, demand for BF greatly outweighs availability, so refinement of the BF protocol, in terms of the time and resources required, is of importance. Our aim was to evaluate the outcomes of an abbreviated BF protocol in patients with defecation disorder-associated chronic constipation and/or faecal incontinence compared to standard BF. METHODS Data were collected from consecutive patients (n = 31; age 54 ± 15; 29 females; 61% functional constipation) undergoing an intentionally abbreviated BF protocol, and compared in a 1:2 ratio with 62 age, gender and functional anorectal disorder-matched control patients undergoing a standard BF. Outcomes included change in symptoms, physiology, patient satisfaction and quality of life. RESULTS On intention to treat, patients in both protocols showed significant improvement in symptom scores and the magnitude did not differ between groups. Impact on quality of life, satisfaction and control over bowel movements improved in both protocols, but satisfaction improved to a greater extent in the standard BF protocol (p = 0.009). Physiological parameters were unchanged after BF apart from improvement in rectal sensation in the standard BF group compared to abbreviated BF (p ⩽ 0.002). CONCLUSIONS Abbreviated anorectal BF offered to patients travelling from far away was not different to a standard BF in providing substantial, at least short term, improvements in symptoms of constipation and faecal incontinence, quality of life and feeling of control over bowel movements. Refinement of the standard BF protocol according to individual patient phenotypes and desired outcomes warrants further study in order to maximize efficacy and improve access for patients.
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Affiliation(s)
- Yoav Mazor
- Royal North Shore Hospital, Reserve Road, St. Leonards, NSW, 2067, Australia University of Sydney, Sydney, NSW, Australia
| | - John E. Kellow
- Gastroenterology Department, Royal North Shore Hospital, St. Leonards, NSW, Australia University of Sydney, Sydney, NSW, Australia
| | - Gillian M. Prott
- Gastroenterology Department, Royal North Shore Hospital, St. Leonards, NSW, Australia
| | - Michael P. Jones
- Psychology Department, Macquarie University, Sydney, NSW, Australia
| | - Allison Malcolm
- Gastroenterology Department, Royal North Shore Hospital, St. Leonards, NSW, Australia University of Sydney, Sydney, NSW, Australia
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Zifan A, Sun C, Gourcerol G, Leroi AM, Mittal RK. Endoflip vs high-definition manometry in the assessment of fecal incontinence: A data-driven unsupervised comparison. Neurogastroenterol Motil 2018; 30:e13462. [PMID: 30216661 PMCID: PMC6249043 DOI: 10.1111/nmo.13462] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 07/30/2018] [Accepted: 08/09/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND How much anal sphincter dysfunction contributes to fecal incontinence (FI) is not clear. High-definition anorectal manometry (HDAM) and functional luminal imaging probe (Endoflip) are two new techniques to study anal sphincter function. AIMS The goal was to compare the diagnostic utility of HDAM and Endoflip using optimal feature(s) in each modality for FI diagnosis. METHODS Blinded classification was carried out on 70 female subjects (32 FI & 38 controls), using 3 prominent machine-learning clustering techniques, with 3 distance metrics. For HDAM, descriptive statistics, shape, and textural features characterizing the spatial relationship of pixels in the HDAM high-pressure zone, and for Endoflip, permutations of pressure and CSA combinations (ie, multiplication, division, or individually) at rest and squeeze were tested. RESULTS Intramodality: (a) Endoflip: Best clustering was obtained using the combination of the ratio of CSA over pressure at 40 and 50 mL at rest, which had significantly better specificity (P < 0.001) than using only pressure at 50 mL, no difference in sensitivity (P = 0.68). (b) HDAM: clustering using textural information at rest had significantly higher specificity compared to using only the maximal pressure at rest (P < 0.001). Intermodality: Clustering results using optimal features were not significantly different with respect to sensitivity or specificity (P > 0.05). Optimal Endoflip feature set differed significantly in specificity compared to HDAM maximal pressure at both rest (P < 0.001) and squeeze (P < 0.001). CONCLUSION Defective anal closure function is fairly sensitive and highly specific in diagnosing FI. Using optimal feature sets, HDAM and Endoflip perform in a similar fashion in diagnosing FI, but are not complementary.
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Affiliation(s)
- Ali Zifan
- Department of Medicine, Division of Gastroenterology, University of California, LA Jolla, CA, USA
| | - Catherine Sun
- Department of Medicine, Division of Gastroenterology, University of California, LA Jolla, CA, USA
| | - Guillaume Gourcerol
- INSERM U1073, Service de Physiologie Digestive, CHU Rouen, INSERM CIC 1404 Rouen, F-76000
| | - Anne M Leroi
- INSERM U1073, Service de Physiologie Digestive, CHU Rouen, INSERM CIC 1404 Rouen, F-76000
| | - Ravinder K Mittal
- Department of Medicine, Division of Gastroenterology, University of California, LA Jolla, CA, USA
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Physical Therapy for Fecal Incontinence in Children with Pelvic Floor Dyssynergia. J Pediatr 2017; 190:74-78. [PMID: 28807359 DOI: 10.1016/j.jpeds.2017.06.074] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 05/26/2017] [Accepted: 06/30/2017] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To determine the efficacy of physical therapy (PT) for fecal incontinence in children with pelvic floor dyssynergia (PFD). STUDY DESIGN Retrospective chart review of children with PFD completing >1 PT session for fecal incontinence at a quaternary children's hospital. The frequency of fecal incontinence (primary outcome), constipation-related medication use, number of bowel movements (in those with <3 per week at baseline) and pelvic floor muscle (PFM) function were captured at baseline and at the final PT visit. Outcomes were categorized as excellent (complete continence), good (>50% decrease in fecal incontinence frequency), fair (not worsening but <50% fecal incontinence frequency decrease), and poor (more frequent fecal incontinence). Compliance with PT was determined by the percentage of attended PT appointments. RESULTS Children included met the following primary outcomes: 27 (42.2%) excellent, 24 (37.5%) good, 11 (17.1%) fair, and 2 (3.1%) poor. Factors associated with an excellent or good outcome included improved PFM functioning and good (≥70% PT attendance) compliance. Children with a history of surgically corrected tethered spinal cord were more likely to have a fair outcome (P = .015). Use of constipation-related medications decreased (1.9 ± 0.7 vs 1.5 ± 0.9, P = .005). Weekly bowel movement frequency increased (1.6 ± 0.6 vs 6.4 ± 4.8, P < .001) in those with infrequent bowel movements (n = 26) at baseline. CONCLUSIONS Pelvic floor PT is effective in the majority of children with fecal incontinence related to PFD. Factors associated with PT efficacy include improved PFM functioning, good compliance with PT, and history of tethered cord.
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Melchior C, Gourcerol G, Bridoux V, Ducrotté P, Quinton JF, Leroi AM. Efficacy of antibiotherapy for treating flatus incontinence associated with small intestinal bacterial overgrowth: A pilot randomized trial. PLoS One 2017; 12:e0180835. [PMID: 28763464 PMCID: PMC5538639 DOI: 10.1371/journal.pone.0180835] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 06/20/2017] [Indexed: 12/12/2022] Open
Abstract
Aim An increase in intestinal gas production due to small intestinal bowel overgrowth (SIBO) is a contributing factor for flatus incontinence. The aims of our study were to assess the efficacy of metronidazole in a select population of patients with flatus incontinence associated with SIBO and to compare its efficacy with that of a combination of simethicone and activated charcoal (SC; Carbosylane) in randomized experimental arms. Methods Adult patients suffering from flatus incontinence associated with SIBO diagnosed by a glucose breath test were enrolled in the study. They were given metronidazole or Carbosylane (SC) for 10 days. The reduction in the mean daily number of gas leakages reported in a 3-day diary before and at the end of the treatment was used as the primary endpoint. Results Of 52 consecutive subjects with flatus incontinence, 23 (44%) had SIBO, 16 (33%) of whom were included in and completed the study. The relative reduction in flatus incontinence episodes was significantly higher in the metronidazole than in the SC group (66.8±34.8% vs. 25±50%, P = 0.03), decreasing by more than 50% in 7 (87.5%) of the subjects in the metronidazole group compared with only 1 (12.5%) in the SC group (odds ratio 1.9, 95% confidence interval 0.9–56.9, P = 0.06). Conclusion Our results show a promising trend indicating that metronidazole might significantly improve flatus incontinence associated with SIBO and might be more successful in treating flatus incontinence than gas absorbents.
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Affiliation(s)
- Chloé Melchior
- INSERM U1073, Service de Physiologie Digestive, CHU Rouen, INSERM CIC 0204 Rouen, Rouen, France
| | - Guillaume Gourcerol
- INSERM U1073, Service de Physiologie Digestive, CHU Rouen, INSERM CIC 0204 Rouen, Rouen, France
| | - Valérie Bridoux
- INSERM U1073, Service de Chirurgie Digestive, CHU Rouen, Rouen, France
| | - Philippe Ducrotté
- INSERM U1073, Service d'Hépato-Gastroentérologie, CHU Rouen, Rouen, France
| | | | - Anne-Marie Leroi
- INSERM U1073, Service de Physiologie Digestive, CHU Rouen, INSERM CIC 0204 Rouen, Rouen, France
- * E-mail:
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