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Aloysius MM, Korsten MA, Radulovic M, Singh K, Lyons BL, Cummings T, Hobson J, Kahal S, Spungen AM, Bauman WA. Lack of improvement in anorectal manometry parameters after implementation of a pelvic floor/anal sphincter biofeedback in persons with motor-incomplete spinal cord injury. Neurogastroenterol Motil 2023; 35:e14667. [PMID: 37743783 DOI: 10.1111/nmo.14667] [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: 12/23/2022] [Revised: 07/30/2023] [Accepted: 08/21/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Effect of biofeedback on improving anorectal manometric parameters in incomplete spinal cord injury is unknown. A short-term biofeedback program investigated any effect on anorectal manometric parameters without correlation to bowel symptoms. METHODS This prospective uncontrolled interventional study comprised three study subject groups, Group 1: sensory/motor-complete American Spinal Injury Association Impairment Scale (AIS) A SCI (n = 13); Group 2 (biofeedback group): sensory incomplete AIS B SCI (n = 17) (n = 3), and motor-incomplete AIS C SCI (n = 8), and AIS D SCI (n = 6); and Group 3: able-bodied (AB) controls (n = 12). High-resolution anorectal manometry (HR-ARM) was applied to establish baseline characteristics in all subjects for anorectal pressure, volume, length of pressure zones, and duration of sphincter squeeze pressure. SCI participants with motor-incomplete SCI were enrolled in pelvic floor/anal sphincter bowel biofeedback training (2 × 6-week training periods comprised of two training sessions per week for 30-45 min per session). HR-ARM was also performed after each of the 6-week periods of biofeedback training. RESULTS Compared to motor-complete or motor-incomplete SCI participants, AB subjects had higher mean intra-rectal pressure, maximal sphincteric pressure, residual anal pressure, recto-anal pressure gradient, and duration of squeeze (p < 0.05 for each of the endpoints). No significant difference was evident at baseline between the motor-complete and motor-incomplete SCI groups. In motor-incomplete SCI subjects, the pelvic floor/anal sphincter biofeedback protocol failed to improve HR-ARM parameters. CONCLUSION Biofeedback training program did not improve anal manometric parameters in subjects with motor-incomplete or sensory-incomplete SCI. Biofeedback did not change physiology, and its effects on symptoms are unknown. INFERENCES Utility of biofeedback is limited in patients with incomplete spinal cord injury in terms of improving HR-ARM parameters.
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Affiliation(s)
- Mark M Aloysius
- Department of Medicine, The Wright Center for Graduate Medical Education, Scranton, Pennsylvania, USA
- Department of Medicine, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Mark A Korsten
- National Center for Medical Consequences of Spinal Cord Injury, James J Peters VA Medical Center, Bronx, New York, USA
- Medical Service, James J Peters VA Medical Center, Bronx, New York, USA
- Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Rehabilitation Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Miroslav Radulovic
- National Center for Medical Consequences of Spinal Cord Injury, James J Peters VA Medical Center, Bronx, New York, USA
- Medical Service, James J Peters VA Medical Center, Bronx, New York, USA
- Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Rehabilitation Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kamaldeep Singh
- Department of Medicine, College of Medicine, Tucson, Arizona, USA
| | - Brian L Lyons
- National Center for Medical Consequences of Spinal Cord Injury, James J Peters VA Medical Center, Bronx, New York, USA
| | | | - Joshua Hobson
- National Center for Medical Consequences of Spinal Cord Injury, James J Peters VA Medical Center, Bronx, New York, USA
| | - Sandeep Kahal
- Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ann M Spungen
- National Center for Medical Consequences of Spinal Cord Injury, James J Peters VA Medical Center, Bronx, New York, USA
- Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Rehabilitation Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - William A Bauman
- National Center for Medical Consequences of Spinal Cord Injury, James J Peters VA Medical Center, Bronx, New York, USA
- Medical Service, James J Peters VA Medical Center, Bronx, New York, USA
- Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Rehabilitation Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Weinstein MM, Pulliam SJ, Keyser L, Richter HE. Use of a motion-based digital therapeutic in women with fecal incontinence: A pilot study. Neurourol Urodyn 2021; 41:475-481. [PMID: 34897780 PMCID: PMC9300000 DOI: 10.1002/nau.24854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 09/23/2021] [Accepted: 11/08/2021] [Indexed: 11/06/2022]
Abstract
AIMS There is limited data addressing the value of vaginal biofeedback (VBF) on fecal incontinence (FI) symptoms. The objective of this pilot study was to evaluate whether use of a motion-based VBF device and app was effective for at-home treatment of women with FI. We hypothesized that VBF would result in improvement in FI symptoms. METHODS A single-arm 10-week prospective pilot trial in women with FI was conducted using the VBF device. The primary outcome was change in St. Mark's score from baseline to week 10. Secondary outcomes included change in 2-week bowel diary and FI quality of life (FIQoL). Statistical analysis included paired t test and Wilcoxon's signed-rank test. RESULTS Of 29 enrolled women, 27 had data available for analysis. Mean (±SD) age was 60.9 (±14.4). 63% (17) subjects were White, 33% (9) were Black. Mean St. Mark's score was 14.6 (±4.4) at baseline and 11.6 (±5.1) at 10-weeks (p = 0.005). Changes in the total FIQol, and three of four subsets of the FIQoL scores were also significantly improved (p < 0.001). Bowel diary showed decrease in FI episodes, baseline 8.4 (±8.73) to 10 weeks 4.8 (±3.79), (p = 0.052). CONCLUSIONS In this pilot study, there was significant improvement in FI symptom-specific severity and quality of life using a vaginal, motion-based device for biofeedback. A larger study is needed to better understand the value of this device, which may be useful for women who prefer a vaginal device, which can be utilized at home compared with standard anal biofeedback for treatment of FI in the clinical setting.
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Affiliation(s)
- Milena M Weinstein
- Department of Obstetrics, Gynecology and Reproductive Biology, Division of Female Pelvic Medicine and Reconstructive Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Samantha J Pulliam
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Tufts University School of Medicine, Renovia Inc., Boston, Massachusetts, USA
| | - Laura Keyser
- Renovia Inc., Boston, MA, USA.,Department of Physical Therapy, Andrews University, Berrien Spring, Michigan, USA
| | - Holly E Richter
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama, USA
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ACG Clinical Guidelines: Management of Benign Anorectal Disorders. Am J Gastroenterol 2021; 116:1987-2008. [PMID: 34618700 DOI: 10.14309/ajg.0000000000001507] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 08/09/2021] [Indexed: 12/11/2022]
Abstract
Benign anorectal disorders of structure and function are common in clinical practice. These guidelines summarize the preferred approach to the evaluation and management of defecation disorders, proctalgia syndromes, hemorrhoids, anal fissures, and fecal incontinence in adults and represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence for these guidelines was assessed using the Grading of Recommendations Assessment, Development and Evaluation process. When the evidence was not appropriate for Grading of Recommendations Assessment, Development and Evaluation, we used expert consensus to develop key concept statements. These guidelines should be considered as preferred but are not the only approaches to these conditions.
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Sharma M, Lowry AC, Rao SS, Whitehead WE, Szarka LA, Hamilton FA, Bharucha AE. A multicenter study of anorectal pressures and rectal sensation measured with portable manometry in healthy women and men. Neurogastroenterol Motil 2021; 33:e14067. [PMID: 33462889 PMCID: PMC8169521 DOI: 10.1111/nmo.14067] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 10/22/2020] [Accepted: 12/01/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The equipment and methods for performing anorectal manometry and biofeedback therapy are different and not standardized. Normal values are influenced by age and sex. Our aims were to generate reference values, examine effects of gender and age, and compare anorectal pressures measured with diagnostic and biofeedback catheters and a portable manometry system. METHODS In this multicenter study, anorectal pressures at rest, during squeeze, and evacuation were measured with diagnostic and biofeedback catheters using Mcompass™ portable device in healthy subjects. Balloon expulsion time and rectal sensation were evaluated. The effects of age and gender were assessed. RESULTS The final dataset comprised 108 (74 women) of 124 participants with normal rectal balloon expulsion time (less than 60 s). During squeeze, anal resting pressure increased by approximately twofold in women and threefold in men. During evacuation, anal pressure exceeded rectal pressure in 87 participants (diagnostic catheter). The specific rectoanal pressures (e.g., resting pressure) were significantly correlated and not different between diagnostic and biofeedback catheters. With the diagnostic catheter, the anal squeeze pressure and rectal pressure during evacuation were greater in men than women (p ≤ 0.02). Among women, women aged 50 years and older had lower anal resting pressure; rectal pressure and the rectoanal gradient during evacuation were greater in older than younger women (p ≤ 0.01). CONCLUSIONS Anal and rectal pressures measured with diagnostic and biofeedback manometry catheters were correlated and not significantly different. Pressures were influenced by age and sex, providing reference values in men and women.
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Affiliation(s)
- Mayank Sharma
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Mn
| | - Ann C. Lowry
- Colon and Rectal Surgery Associates, Minneapolis, Mn
| | - Satish S. Rao
- Division of Gastroenterology, Augusta University, Augusta, Ga
| | - William E. Whitehead
- Center for Functional GI and Motility Disorders, University of North Carolina, Chapel Hill, NC
| | | | - Frank A. Hamilton
- National Institute of Digestive Diseases, Kidney, and Diabetes, Bethesda, MD
| | - Adil E. Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Mn
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Mundet L, Rofes L, Ortega O, Cabib C, Clavé P. Kegel Exercises, Biofeedback, Electrostimulation, and Peripheral Neuromodulation Improve Clinical Symptoms of Fecal Incontinence and Affect Specific Physiological Targets: An Randomized Controlled Trial. J Neurogastroenterol Motil 2021; 27:108-118. [PMID: 33109777 PMCID: PMC7786087 DOI: 10.5056/jnm20013] [Citation(s) in RCA: 3] [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: 12/29/2020] [Revised: 04/16/2020] [Accepted: 07/03/2020] [Indexed: 02/06/2023] Open
Abstract
Background/Aims Fecal incontinence (FI) is a prevalent condition among community-dwelling women, and has a major impact on quality of life (QoL). Research on treatments commonly used in clinical practice—Kegel exercises, biofeedback, electrostimulation, and transcutaneous neuromodulation—give discordant results and some lack methodological rigor, making scientific evidence weak. The aim is to assess the clinical efficacy of these 4 treatments on community-dwelling women with FI and their impact on severity, QoL and anorectal physiology. Methods A randomized controlled trial was conducted on 150 females with FI assessed with anorectal manometry and endoanal ultrasonography, and pudendal nerve terminal motor latency, anal/rectal sensory-evoked-potentials, clinical severity, and QoL were determined. Patients were randomly assigned to one of the following groups Kegel (control), biofeedback + Kegel, electrostimulation + Kegel, and neuromodulation + Kegel, treated for 3 months and re-evaluated, then followed up after 6 months. Results Mean age was 61.09 ± 12.17. Severity of FI and QoL was significantly improved in a similar way after all treatments. The effect on physiology was treatment-specific Kegel and electrostimulation + Kegel, increased resting pressure (P < 0.05). Squeeze pressures strongly augmented with biofeedback + Kegel, electrostimulation + Kegel and neuromodulation + Kegel (P < 0.01). Endurance of squeeze increased in biofeedback + Kegel and electrostimulation + Kegel (P < 0.01). Rectal perception threshold was reduced in the biofeedback + Kegel, electrostimulation + Kegel, and neuromodulation + Kegel (P < 0.05); anal sensory-evoked-potentials latency shortened in patients with electrostimulation + Kegel (P < 0.05). Conclusions The treatments for FI assessed have a strong and similar efficacy on severity and QoL but affect specific pathophysiological mechanisms. This therapeutic specificity can help to develop more efficient multimodal algorithm treatments for FI based on pathophysiological phenotypes.
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Affiliation(s)
- Lluís Mundet
- Gastrointestinal Physiology Laboratory, Department of Surgery, Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain.,Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain
| | - Laia Rofes
- Gastrointestinal Physiology Laboratory, Department of Surgery, Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain.,Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain.,Neos Surgery, Parc Tecnològic del Vallès, Cerdanyola del Vallès, Barcelona, Spain
| | - Omar Ortega
- Gastrointestinal Physiology Laboratory, Department of Surgery, Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain.,Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain
| | - Christopher Cabib
- Gastrointestinal Physiology Laboratory, Department of Surgery, Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain
| | - Pere Clavé
- Gastrointestinal Physiology Laboratory, Department of Surgery, Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain.,Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain
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Abstract
Nine percent of adult women experience episodes of fecal incontinence at least monthly. Fecal incontinence is more common in older women and those with chronic bowel disturbance, diabetes, obesity, prior anal sphincter injury, or urinary incontinence. Fecal incontinence negatively affects quality of life and mental health and is associated with increased risk of nursing home placement. Fewer than 30% of women with fecal incontinence seek care, and lack of information about effective solutions is an important barrier for both patients and health care professionals. Even among women with both urinary and fecal incontinence presenting for urogynecologic care, the rate of verbal disclosure of fecal incontinence symptoms remains low. This article provides an overview of the evaluation and management of fecal incontinence for the busy obstetrician-gynecologist, incorporating existing guidance from the American College of Obstetricians and Gynecologists, the American College of Gastroenterology, and the American Society of Colon and Rectal Surgeons. The initial clinical evaluation of fecal incontinence requires a focused history and physical examination. Recording patient symptoms using a standard diary or questionnaire can help document symptoms and response to treatment. Invasive diagnostic testing and imaging generally are not needed to initiate treatment but may be considered in complex cases. Most women have mild symptoms that will improve with optimized stool consistency and medications. Additional treatment options include pelvic floor muscle strengthening with or without biofeedback, devices placed anally or vaginally, and surgery, including sacral neurostimulation, anal sphincteroplasty, and, for severely affected individuals for whom other interventions fail, colonic diversion.
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Affiliation(s)
- Heidi W Brown
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Kaiser Permanente San Diego, San Diego, California; and the Department of Women's Health, Dell Medical School, University of Texas at Austin, Austin Texas
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7
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Abstract
Defecatory disorders can include structural, neurological, and functional disorders in addition to concomitant symptoms of fecal incontinence, functional anorectal pain, and pelvic floor dyssynergia. These disorders greatly affect quality of life and healthcare costs. Treatment for pelvic floor disorders can include medications, botulinum toxin, surgery, physical therapy, and biofeedback. Pelvic floor muscle training for pelvic floor disorders aims to enhance strength, speed, and/or endurance or coordination of voluntary anal sphincter and pelvic floor muscle contractions. Biofeedback therapy builds on physical therapy by incorporating the use of equipment to record or amplify activities of the body and feed the information back to the patients. Biofeedback has demonstrated efficacy in the treatment of chronic constipation with dyssynergic defecation, fecal incontinence, and low anterior resection syndrome. Evidence for the use of biofeedback in levator ani syndrome is conflicting. In comparing biofeedback to pelvic floor muscle training alone, studies suggest that biofeedback is superior therapy.
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Affiliation(s)
- Melissa Hite
- Department of Surgery, Division of Colon and Rectal Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Thomas Curran
- Department of Surgery, Division of Colon and Rectal Surgery, Medical University of South Carolina, Charleston, South Carolina
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Xu L, Fu C, Zhang Q, Xiong F, Peng L, Liang Z, Chen L, He C, Wei Q. Efficacy of biofeedback, repetitive transcranial magnetic stimulation and pelvic floor muscle training for female neurogenic bladder dysfunction after spinal cord injury: a study protocol for a randomised controlled trial. BMJ Open 2020; 10:e034582. [PMID: 32759239 PMCID: PMC7409967 DOI: 10.1136/bmjopen-2019-034582] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 05/14/2020] [Accepted: 06/23/2020] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Neurogenic bladder dysfunction is prevalent in female patients with spinal cord injury (SCI), and previous guidelines have recommended pelvic floor muscle training (PFMT) for first-line conservative treatment. However, the actual regimen of PFMT varies widely and the single treatment does not satisfy the need of some patients. Therefore, this study aims to provide a detailed rationale and methodology for comparing the effectiveness of PFMT, biofeedback and repetitive transcranial magnetic stimulation (rTMS) as adjunct treatments for neurogenic bladder dysfunction. METHODS AND ANALYSIS This trial is a single-centre randomised controlled trial for female patients with urinary incontinence (UI) in phase of chronic SCI. Eligible participants will be randomised to one of four arms: (1) PFMT, (2) PFMT with biofeedback, (3) PFMT and rTMS and (4) PFMT with biofeedback and rTMS. There will be 44 participants in each arm and all the subjects will undergo 20 treatment sessions, five times a week for 4 weeks. The outcomes will be evaluated at 4 weeks, 3 months and 6 months after randomisation. The primary outcome is the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form, and the secondary outcomes include bladder diary, pelvic floor muscle function and the International Spinal Cord Injury Quality of Life Basic Data Set. ETHICS AND DISSEMINATION The Clinical Research and Biomedical Ethics Committee of the West China Hospital, Sichuan University has approved this trial and the approval number is 2019-885. All participants will be provided written informed consent after verification of the eligibility criteria. The results of this study will be accessible in peer-reviewed publications and be presented at academic conferences. TRIAL REGISTRATION NUMBER Chinese Clinical Trial Registry (ChiCTR1900026126).
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Affiliation(s)
- Lin Xu
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, PR China
| | - Chenying Fu
- State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
| | - Qing Zhang
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, PR China
| | - Feng Xiong
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, PR China
| | - Lihong Peng
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, PR China
| | - Zejun Liang
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, PR China
| | - Li Chen
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, PR China
| | - Chengqi He
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, PR China
| | - Quan Wei
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, PR China
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Ohara N, Takahashi H, Katsuyama S, Doki Y, Mori M, Nakajima K. Electrical contraction of the anal sphincter for intraoperative visualization of anal function. MINIM INVASIV THER 2020; 31:127-136. [DOI: 10.1080/13645706.2020.1773855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Nobuyoshi Ohara
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Hidekazu Takahashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Shinsuke Katsuyama
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
- Department of Next Generation Endoscopic Intervention (Project ENGINE), Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Masaki Mori
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Kiyokazu Nakajima
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
- Department of Next Generation Endoscopic Intervention (Project ENGINE), Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
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Andy UU, Jelovsek JE, Carper B, Meyer I, Dyer KY, Rogers RG, Mazloomdoost D, Korbly NB, Sassani JC, Gantz MG. Impact of treatment for fecal incontinence on constipation symptoms. Am J Obstet Gynecol 2020; 222:590.e1-590.e8. [PMID: 31765640 DOI: 10.1016/j.ajog.2019.11.1256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 10/17/2019] [Accepted: 11/17/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Defecatory symptoms, such as a sense of incomplete emptying and straining with bowel movements, are paradoxically present in women with fecal incontinence. Treatments for fecal incontinence, such as loperamide and biofeedback, can worsen or improve defecatory symptoms, respectively. The primary aim of this study was to compare changes in constipation symptoms in women undergoing treatment for fecal incontinence with education only, loperamide, anal muscle exercises with biofeedback or both loperamide and biofeedback. Our secondary aim was to compare changes in constipation symptoms among responders and nonresponders to fecal incontinence treatment. STUDY DESIGN This was a planned secondary analysis of a randomized controlled trial comparing 2 first-line therapies for fecal incontinence in a 2 × 2 factorial design. Women with at least monthly fecal incontinence and normal stool consistency were randomized to 4 groups: (1) oral placebo plus education only, (2) oral loperamide plus education only, (3) placebo plus anorectal manometry-assisted biofeedback, and (4) loperamide plus biofeedback. Defecatory symptoms were measured using the Patient Assessment of Constipation Symptoms questionnaire at baseline, 12 weeks, and 24 weeks. The Patient Assessment of Constipation Symptoms consists of 12 items that contribute to a global score and 3 subscales: stool characteristics/symptoms (hardness of stool, size of stool, straining, inability to pass stool), rectal symptoms (burning, pain, bleeding, incomplete bowel movement), and abdominal symptoms (discomfort, pain, bloating, cramps). Scores for each subscale as well as the global score range from 0 (no symptoms) to 4 (maximum score), with negative change scores representing improvement in defecatory symptoms. Responders to fecal incontinence treatment were defined as women with a minimally important clinical improvement of ≥5 points on the St Mark's (Vaizey) scale between baseline and 24 weeks. Intent-to-treat analysis was performed using a longitudinal mixed model, controlling for baseline scores, to estimate changes in Patient Assessment of Constipation Symptoms scores from baseline through 24 weeks. RESULTS At 24 weeks, there were small changes in Patient Assessment of Constipation Symptoms global scores in all 4 groups: oral placebo plus education (-0.3; 95% confidence interval, -0.5 to -0.1), loperamide plus education (-0.1, 95% confidence interval, -0.3 to0.0), oral placebo plus biofeedback (-0.3, 95% confidence interval, -0.4 to -0.2), and loperamide plus biofeedback (-0.3, 95% confidence interval, -0.4 to -0.2). No differences were observed in change in Patient Assessment of Constipation Symptoms scores between women randomized to placebo plus education and those randomized to loperamide plus education (P = .17) or placebo plus biofeedback (P = .82). Change in Patient Assessment of Constipation Symptoms scores in women randomized to combination loperamide plus biofeedback therapy was not different from that of women randomized to treatment with loperamide or biofeedback alone. Responders had greater improvement in Patient Assessment of Constipation Symptoms scores than nonresponders (-0.4; 95% confidence interval, -0.5 to -0.3 vs -0.2; 95% confidence interval, -0.3 to -0.0, P < .01, mean difference, 0.2, 95% confidence interval, 0.1-0.4). CONCLUSION Change in constipation symptoms following treatment of fecal incontinence in women are small and are not significantly different between groups. Loperamide treatment for fecal incontinence does not worsen constipation symptoms among women with normal consistency stool. Women with clinically significant improvement in fecal incontinence symptoms report greater improvement in constipation symptoms.
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Affiliation(s)
- Uduak U Andy
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA.
| | - J Eric Jelovsek
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | | | - Isuzu Meyer
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | - Keisha Y Dyer
- Department of Obstetrics and Gynecology, Kaiser Permanente, San Diego, CA
| | - Rebecca G Rogers
- Department of Women's Health, Dell Medical School, University of Texas at Austin. Austin, TX; University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
| | - Nicole B Korbly
- Department of Obstetrics and Gynecology, Alpert Medical School of Brown University, Providence, RI
| | - Jessica C Sassani
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh Medical Center, Pittsburgh, PA
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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] [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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Jelovsek JE. Biofeedback or loperamide for faecal incontinence in women – Author's reply. Lancet Gastroenterol Hepatol 2019; 4:904-905. [DOI: 10.1016/s2468-1253(19)30334-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 08/30/2019] [Indexed: 10/25/2022]
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Jelovsek JE, Markland AD, Whitehead WE, Barber MD, Newman DK, Rogers RG, Dyer K, Visco AG, Sutkin G, Zyczynski HM, Carper B, Meikle SF, Sung VW, Gantz MG. Controlling faecal incontinence in women by performing anal exercises with biofeedback or loperamide: a randomised clinical trial. Lancet Gastroenterol Hepatol 2019; 4:698-710. [PMID: 31320277 PMCID: PMC6708078 DOI: 10.1016/s2468-1253(19)30193-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 05/08/2019] [Accepted: 05/09/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Well designed, large comparative effectiveness trials assessing the efficacy of primary interventions for faecal incontinence are few in number. The objectives of this study were to compare different combinations of anorectal manometry-assisted biofeedback, loperamide, education, and oral placebo. METHODS In this randomised factorial trial, participants were recruited from eight clinical sites in the USA. Women with at least one episode of faecal incontinence per month in the past 3 months were randomly assigned 0·5:1:1:1 to one of four groups: oral placebo plus education only, placebo plus anorectal manometry-assisted biofeedback, loperamide plus education only, and loperamide plus anorectal manometry-assisted biofeedback. Participants received 2 mg per day of loperamide or oral placebo with the option of dose escalation or reduction. Women assigned to biofeedback received six visits, including strength and sensory biofeedback training. All participants received a standardised faecal incontinence patient education pamphlet and were followed for 24 weeks after starting treatment. The primary endpoint was change in St Mark's (Vaizey) faecal incontinence severity score between baseline and 24 weeks, analysed by intention-to-treat using general linear mixed modelling. Investigators, interviewers, and outcome evaluators were masked to biofeedback assignment. Participants and all study staff other than the research pharmacist were masked to medication assignment. Randomisation took place within the electronic data capture system, was stratified by site using randomly permuted blocks (block size 7), and the sizes of the blocks and the allocation sequence were known only to the data coordinating centre. This trial is registered with ClinicalTrials.gov, number NCT02008565. FINDINGS Between April 1, 2014, and Sept 30, 2015, 377 women were enrolled, of whom 300 were randomly assigned to placebo plus education (n=42), placebo plus biofeedback (n=84), loperamide plus education (n=88), and the combined intervention of loperamide plus biofeedback (n=86). At 24 weeks, there were no differences between loperamide versus placebo (model estimated score change -1·5 points, 95% CI -3·4 to 0·4, p=0·12), biofeedback versus education (-0·7 points, -2·6 to 1·2, p=0·47), and loperamide and biofeedback versus placebo and biofeedback (-1·9 points, -4·1 to 0·3, p=0·092) or versus loperamide plus education (-1·1 points, -3·4 to 1·1, p=0·33). Constipation was the most common grade 3 or higher adverse event and was reported by two (2%) of 86 participants in the loperamide and biofeedback group and two (2%) of 88 in the loperamide plus education group. The percentage of participants with any serious adverse events did not differ between the treatment groups. Only one serious adverse event was considered related to treatment (small bowel obstruction in the placebo and biofeedback group). INTERPRETATION In women with normal stool consistency and faecal incontinence bothersome enough to seek treatment, we were unable to find evidence against the null hypotheses that loperamide is equivalent to placebo, that anal exercises with biofeedback is equivalent to an educational pamphlet, and that loperamide and biofeedback are equivalent to oral placebo and biofeedback or loperamide plus an educational pamphlet. Because these are common first-line treatments for faecal incontinence, clinicians could consider combining loperamide, anal manometry-assisted biofeedback, and a standard educational pamphlet, but this is likely to result in only negligible improvement over individual therapies and patients should be counselled regarding possible constipation. FUNDING Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Institutes of Health Office of Research on Women's Health.
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Affiliation(s)
- J Eric Jelovsek
- Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA.
| | - Alayne D Markland
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Birmingham, AL, USA
| | - William E Whitehead
- Department of Gastroenterology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Matthew D Barber
- Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - Diane K Newman
- Division of Urology, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Rebecca G Rogers
- Departments of Obstetrics and Gynecology and Surgery, University of New Mexico Health Sciences Center, Albuquerque, NM, USA; Department of Women's Health, Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | - Keisha Dyer
- Department of Obstetrics and Gynecology, Kaiser Permanente, San Diego, CA, USA
| | - Anthony G Visco
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - Gary Sutkin
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Magee-Womens Research Institute, Pittsburgh, PA, USA; Department of Obstetrics and Gynecology, University of Missouri, Kansas City, MO, USA
| | - Halina M Zyczynski
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Magee-Womens Research Institute, Pittsburgh, PA, USA
| | | | | | - Vivian W Sung
- Department of Obstetrics and Gynecology, Alpert Medical School of Brown University, Providence, RI, USA
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Bocchini R, Chiarioni G, Corazziari E, Pucciani F, Torresan F, Alduini P, Bassotti G, Battaglia E, Ferrarini F, Galeazzi F, Londoni C, Rossitti P, Usai Satta P, Iona L, Marchi S, Milazzo G, Altomare DF, Barbera R, Bove A, Calcara C, D'Alba L, De Bona M, Goffredo F, Manfredi G, Naldini G, Neri MC, Turco L, La Torre F, D'Urso AP, Berni I, Balestri MA, Busin N, Boemo C, Bellini M. Pelvic floor rehabilitation for defecation disorders. Tech Coloproctol 2019; 23:101-115. [PMID: 30631977 DOI: 10.1007/s10151-018-1921-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 12/26/2018] [Indexed: 12/17/2022]
Abstract
Pelvic floor rehabilitation is frequently recommended for defecation disorders, in both constipation and fecal incontinence. However, the lack of patient selection, together with the variety of rehabilitation methods and protocols, often jeopardize the results of this approach, causing difficulty in evaluating outcomes and addressing proper management, and above all, in obtaining scientific evidence for the efficacy of these methods for specific indications. The authors represent different gastroenterological and surgical scientific societies in Italy, and their aim was to identify the indications and agree on treatment protocols for pelvic floor rehabilitation of patients with defecation disorders. This was achieved by means of a modified Delphi method, utilizing a working team (10 members) which developed the statements and a consensus group (15 members, different from the previous ones) which voted twice also suggesting modifications of the statements.
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Affiliation(s)
- R Bocchini
- Gastroenterology Unit, Malatesta Novello Private Hospital, Cesena, Italy.
| | - G Chiarioni
- RFF Division of Gastroenterology, University of Verona, Verona, Italy.,Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - E Corazziari
- Department of Gastroenterology, Istituto Clinico Humanitas, Milan, Italy
| | - F Pucciani
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - F Torresan
- Department of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - P Alduini
- Gastroenterology and Endoscopy Unit, San Luca Hospital, Lucca, Italy
| | - G Bassotti
- Gastroenterology and Hepatology Section, Department of Medicine, University of Perugia Medical School, Perugia, Italy
| | - E Battaglia
- Gastroenterology and Endoscopy Unit, Cardinal Massaia Hospital, Asti, Italy
| | - F Ferrarini
- Endoscopy Unit, San Clemente Private Hospital, Mantua, Italy
| | - F Galeazzi
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - C Londoni
- Gastroenterology and Endoscopy Unit, ASST "Maggiore", Crema, Cremona, Italy
| | - P Rossitti
- Gastroenterology Unit, S. Maria della Misericordia Hospital, Udine, Italy
| | - P Usai Satta
- Gastroenterology Unit, G. Brotzu Hospital, Cagliari, Italy
| | - L Iona
- Early Rehabilitation Department, S. Maria della Misericordia Hospital, Udine, Italy
| | - S Marchi
- Gastrointestinal Unit, Departmentt. of General Surgery, University of Pisa, Pisa, Italy
| | - G Milazzo
- U.O.Lungodegenza e Medicina, Ospedale Vittorio Emanuele III, Salemi, Tp, Italy
| | - D F Altomare
- Department of Emergency and Organ Transplantation (DETO) and Interdepart mental Research Center for Pelvic Floor Dysfunction (CIRPAP), University Aldo Moro, Policlinico, Bari, Italy
| | - R Barbera
- San Giuseppe Multimedica Hospital, Milan, Italy
| | - A Bove
- Gastroenterology and Endoscopy Unit, Department of Gastroenterology, A. Cardarelli Hospital, Naples, Italy
| | - C Calcara
- Gastroenterology Unit, SSVD Gastroenterologia, Ospedale SS Trinità, Borgomanero, No, Italy
| | - L D'Alba
- Gastroenterology and Digestive Endoscopy Unit, San Giovanni-Addolorata Hospital, Rome, Italy
| | - M De Bona
- Gastroenterology and Endoscopy Unit, Feltre Hospital, Feltre, Bl, Italy
| | - F Goffredo
- Gastroenterology and Endoscopy Unit, San Camillo-Forlanini Hospital, Rome, Italy
| | - G Manfredi
- Department of Gastroenterology and Digestive Endoscopy, Crema Hospital, ASST CREMA, Crema, Italy
| | - G Naldini
- Proctological and Perineal Surgery Unit, Cisanello University Hospital, Pisa, Italy
| | - M C Neri
- Gastroenterology Unit, Geriatric Institute "Pio Albergo Trivulzio", Milan, Italy
| | - L Turco
- Department of Digestive Physiopathology, Healte Center "Cittadella della Salute", Lecce, Italy
| | - F La Torre
- Department of Surgical Sciences, University "La Sapienza", Policlinico Umberto I, Rome, Italy
| | | | - I Berni
- Rehabilitation Department, San Luca Hospital, Lucca, Italy
| | - M A Balestri
- Proctological and Perineal Surgery Unit, Cisanello University Hospital, Pisa, Italy
| | - N Busin
- Rehabilitation Department, Villa Igea Private Hospital, Forlì, Italy
| | - C Boemo
- Early Rehabilitation Department, S. Maria della Misericordia Hospital, Udine, Italy
| | - M Bellini
- Gastrointestinal Unit, Department of General Surgery, University of Pisa, Pisa, Italy
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Weledji EP. Electrophysiological Basis of Fecal Incontinence and Its Implications for Treatment. Ann Coloproctol 2017; 33:161-168. [PMID: 29159162 PMCID: PMC5683965 DOI: 10.3393/ac.2017.33.5.161] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 03/30/2017] [Indexed: 12/13/2022] Open
Abstract
The majority of patients with neuropathic incontinence and other pelvic floor conditions associated with straining at stool have damage to the pudendal nerves distal to the ischial spine. Sacral nerve stimulation appears to be a promising innovation and has been widely adopted and currently considered the standard of care for adults with moderate to severe fecal incontinence and following failed sphincter repair. From a decision-to-treat perspective, the short-term efficacy is good (70%-80%), but the long-term efficacy of sacral nerve stimulation is around 50%. Newer electrophysiological tests and improved anal endosonography would more effectively guide clinical decision making.
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Affiliation(s)
- Elroy Patrick Weledji
- Department of Surgery and Obstetrics and Gynecology, Faculty of Health Sciences, University of Buea, Buea, Cameroon
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