1
|
Abstract
Neurogenic bowel dysfunction ranks as one of the most frequent problems experienced by people with multiple sclerosis (MS); it is one of the first symptoms to appear at disease onset and continues throughout the course of the disease. This review, based on literature searches of Medline and PubMed, examines bowel dysfunction causes and cofactors (ie, impaired mobility, fatigue, depression and anxiety, childbirth) that occur over the course of the disease. Coverage includes management of bowel dysfunction with noninvasive methods, including diet and fluid intake, together with pharmacologic treatments for constipation and fecal incontinence as well as more advanced treatments (ie, biofeedback, abdominal massage, transanal irrigation, posterior tibial nerve stimulation), caregiver-provided treatments and extended care facilities. Bowel dysfunction problems and related cofactors impact quality of life throughout the MS disease course, requiring appropriate interventions to improve and/or maintain the quality of life of the individual with MS.
Collapse
Affiliation(s)
- Elsie E Gulick
- School of Nursing, Rutgers, The State University of New Jersey, Newark, NJ, USA (EEG)
| |
Collapse
|
2
|
[Analysis of anorectal manometry data in central and peripheral neurological deseases: Review of the literature]. Prog Urol 2022; 32:1505-1518. [PMID: 36030152 DOI: 10.1016/j.purol.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 07/26/2022] [Accepted: 08/12/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Peripheral or central neurological deseases are providers of anorectal disorders of variable clinical expression (constipation, dyschezia, faecal incontinence (FI)…). Anorectal manometry (ARM) participates in their exploration to determine the underlying mechanisms, guide and optimize treatments. The objective of this work was to determine if there is a pattern of ARM data in neurological populations. MATERIALS ET METHODS Literature review from PubMed, Cochrane and Google scholar databases, using the following keywords: parkinsonian disorders; parkinson's disease; multiple slcerosis; neurolog*; spinal cord injury; spina bifida occulta; stroke; pudendal; endometriosis; peripheral nervous system diseases. 196 articles were isolated and finally 45 retained after reading the title and the abstract. RESULTS Data comparison was difficult due to the heterogeneity of techniques and thresholds used. In central lesions, resting and squeeze anal pressures were often altered. The presence of FI or constipation, the sex and the lesion level were factors influencing these data (low if complete injury, women or EDSS>5.5). In case of peripheral lesion, it is the anal tone and the contraction that varied the symptomatology. The sensory thresholds were variable regardless of the impairment. CONCLUSION This review did not identify a data pattern of ARM in central and peripheral neurological deseases. Gradual standardization of techniques and protocols will allow better comparison of data.
Collapse
|
3
|
Sparaco M, Bonavita S. Pelvic Floor Dysfunctions and Their Rehabilitation in Multiple Sclerosis. J Clin Med 2022; 11:jcm11071941. [PMID: 35407549 PMCID: PMC8999571 DOI: 10.3390/jcm11071941] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/29/2022] [Accepted: 03/29/2022] [Indexed: 12/17/2022] Open
Abstract
Urinary, bowel, and sexual dysfunctions are the most frequent and disabling pelvic floor (PF) disorders in patients with multiple sclerosis (MS). PF dysfunction negatively impacts the performance of daily living activities, walking, and the physical dimension of quality of life (QoL) in people with MS. Patient-reported outcomes on sphincteric functioning could be useful to detect PF disorders and their impact on patients’ lives. PF rehabilitation proposed by Kegel is based on a series of regularly repeated exercises for “the functional restoration of the perineal muscles”. Over time, various therapeutic modalities have been added to PF muscles exercises, through the application of physical or instrumental techniques, such as intravaginal neuromuscular electrical stimulation, electromyographic biofeedback, transcutaneous tibial nerve stimulation. PF rehabilitation has been applied in MS treatment, with improvements of lower urinary tract symptoms severity, QoL, level of anxiety and depression, and sexual dysfunction. This review aims to examine the different PF disorders in MS to evaluate the application of PF rehabilitation in MS and to highlight its advantages and limits, suggesting a multidisciplinary management of PF disorders, with a well-deserved space reserved for PF rehabilitation.
Collapse
Affiliation(s)
| | - Simona Bonavita
- Correspondence: ; Tel.: +39-081-5666742; Fax: +39-081-5665096
| |
Collapse
|
4
|
Kovari M, Stovicek J, Novak J, Havlickova M, Mala S, Busch A, Kolar P, Kobesova A. Anorectal dysfunction in multiple sclerosis patients: A pilot study on the effect of an individualized rehabilitation approach. NeuroRehabilitation 2021; 50:89-99. [PMID: 34776431 PMCID: PMC8925101 DOI: 10.3233/nre-210226] [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] [Indexed: 11/15/2022]
Abstract
BACKGROUND: Anorectal dysfunction (ARD), especially bowel incontinence, frequently compromises the quality of life in multiple sclerosis (MS) patients. The effect of rehabilitation procedures has not been clearly established. OBJECTIVE: To determine the effect of an individualized rehabilitation approach on bowel incontinence and anorectal pressures. METHODS: MS patients with ARD underwent 6-months of individually targeted biofeedback rehabilitation. High resolution anorectal manometry (HRAM) and St. Mark’s Fecal Incontinence Scores (SMIS) were completed prior to rehabilitation, after 10 weeks of supervised physiotherapy, and after 3 months of self-treatment. RESULTS: Ten patients (50%) completed the study. Repeated measures analysis of variance (ANOVA) demonstrated significant improvement in the SMIS questionnaire over time [14.00 baseline vs. 9.70 after supervised physiotherapy vs. 9.30 after self-treatment (p = 0.005)]. No significant improvements over time were noted in any HRAM readings: maximal pressure [49.85 mmHg baseline vs. 57.60 after supervised physiotherapy vs. 60.88 after self-treatment (p = 0.58)], pressure endurance [36.41 vs. 46.89 vs. 49.95 (p = 0.53)], resting pressure [55.83, vs 52.69 vs. 51.84 (p = 0.704)], or area under the curve [230.0 vs. 520.8 vs. 501.9 (p = 0.16)]. CONCLUSIONS: The proposed individualized rehabilitation program supports a positive overall effect on anorectal dysfunction in MS patients.
Collapse
Affiliation(s)
- Martina Kovari
- Department of Rehabilitation and Sports Medicine, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Jan Stovicek
- Department of Internal Medicine, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Jakub Novak
- Department of Rehabilitation and Sports Medicine, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Michaela Havlickova
- Department of Rehabilitation and Sports Medicine, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Sarka Mala
- Department of Internal Medicine, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Andrew Busch
- Department of Health and Human Kinetics, Ohio Wesleyan University, Delaware, OH, USA
| | - Pavel Kolar
- Department of Rehabilitation and Sports Medicine, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Alena Kobesova
- Department of Rehabilitation and Sports Medicine, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| |
Collapse
|
5
|
Delaune M, Desprez C, Leroi AM. [Anorectal disorders in patients with multiple sclerosis: Physiopathology, prevalence, impact, and management]. Prog Urol 2019; 29:1011-1020. [PMID: 31521507 DOI: 10.1016/j.purol.2019.08.274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 08/24/2019] [Accepted: 08/26/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Neurogenic bowel disorders (NBD) are frequently observed in patients with multiple sclerosis (MS); the prevalence of constipation is estimated to be 35-54 % and fecal incontinence between 29 and 51 % (LE 4). They contribute to the deterioration of patients' quality of life (LE 4). The aim of this article is to review the literature on the physiopathology, prevalence, impact, and management of bowel disorders in patients with MS in order to educate caregivers about their existence and thus help them to optimize therapeutic choices. MATERIALS AND METHODS A bibliographic search was conducted between 2000 and 2019 and 31 relevant scientific articles were selected. Relevant references were subsequently added, bringing the total to 50 articles. A level of scientific evidence (LE) was assigned to each article, except for literature reviews. RESULTS The origin of NBD is multifactorial and includes impairment of neurological pathways, polypharmacy, behavioural disorders, and loss of autonomy (LE 4). Patients with MS should be questioned about their bowel habits and, in cases of proven NBD, specific management options should be offered. The first step concerns the dietary and lifestyle rules associated with the use of laxatives, suppositories, and/or enemas (LE 4). In the event of failure, therapies such as abdominal massages (LE 1 and 2), biofeedback and transanal irrigation can be proposed (LE 4). Anterograde colonic irrigation may also be an option (LE 4). The efficacy of stimulating the posterior tibial nerve needs to be proven (LE 4). The implantation of a sacral neuromodulation device is, for the moment, difficult due to the impossibility of performing a spinal magnetic resonance imaging during follow-up. A stoma improves the quality of life of patients and should not be proposed too late. CONCLUSION Effective treatment of NBD improves the quality of life of patients and reduces the incidence of bladder disorders (LE 4).
Collapse
Affiliation(s)
- M Delaune
- Service de physiologie digestive, urinaire, respiratoire et de l'exercice, CHU de Rouen, 76000 Rouen, France.
| | - C Desprez
- Service de physiologie digestive, urinaire, respiratoire et de l'exercice, CHU de Rouen, 76000 Rouen, France
| | - A M Leroi
- Inserm 1073, CIC-CRB 1404, Service de physiologie urinaire, digestive, respiratoire et de l'exercice, UNIROUEN, Normandie université, CHU de Rouen, 76000, Rouen, France
| |
Collapse
|
6
|
Das R, Wille L, Zhang L, Chen C, Winchester W, Selimkhanov J, Wykosky J, Apgar JF, Burke JM, Rogge M, Hua F, Vakilynejad M. A quantitative systems pharmacology model of colonic motility with applications in drug development. J Pharmacokinet Pharmacodyn 2019; 46:485-498. [DOI: 10.1007/s10928-019-09651-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 08/09/2019] [Indexed: 12/17/2022]
|
7
|
Fröhlich K, Linker RA, Engelhorn T, Dörfler A, Lee DH, Huhn K, Schwab S, Hilz MJ, Seifert F, Winder K. Brain MRI Lesions are Related to Bowel Incontinence in Multiple Sclerosis. J Neuroimaging 2018; 29:211-217. [PMID: 30537408 DOI: 10.1111/jon.12589] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 11/21/2018] [Accepted: 11/30/2018] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND AND PURPOSE Bowel incontinence in multiple sclerosis might be associated with specific lesion sites. This study intended to determine associations between bowel incontinence and cerebral multiple sclerosis lesions using a voxel-wise lesion symptom mapping analysis. METHODS We conducted a retrospective study of multiple sclerosis patients with self-reported bowel incontinence and matched controls. Lesions were manually outlined on T2-weighted MRI scans and transformed into stereotaxic space. We performed a voxel-wise subtraction analysis subtracting the lesion overlap of patients without from patients with bowel incontinence. Finally, we compared the absence or presence of bowel incontinence between patients with and without lesions in a given voxel using the Liebermeister test. RESULTS A total of 51 patients were included in the study. The analysis yielded associations between bowel incontinence and lesions in the supramarginal gyrus of the left secondary somatosensory cortex and another lesion cluster in the right parahippocampal gyrus and amygdala. CONCLUSIONS Our analysis indicates associations between bowel incontinence and lesions in the left supramarginal gyral area contributing to integrating anorectal-visceral sensation and in the right parahippocampal gyrus and amygdala contributing to generating visceral autonomic arousal states. Moreover, our results suggest left hemispheric dominance of sensory visceral integration, while limbic areas of the right hemisphere seem to contribute to the autonomic component of the defecation process. A limitation of our study is the retrospective evaluation of the bowel incontinence status based on medical records. Further research should evaluate the bowel incontinence status in multiple sclerosis patients prospectively to overcome the limitations of the current study.
Collapse
Affiliation(s)
- Kilian Fröhlich
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Ralf A Linker
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Tobias Engelhorn
- Department of Neuroradiology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Arnd Dörfler
- Department of Neuroradiology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - De-Hyung Lee
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Konstantin Huhn
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Max J Hilz
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Frank Seifert
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Klemens Winder
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| |
Collapse
|
8
|
Preziosi G, Gordon-Dixon A, Emmanuel A. Neurogenic bowel dysfunction in patients with multiple sclerosis: prevalence, impact, and management strategies. Degener Neurol Neuromuscul Dis 2018; 8:79-90. [PMID: 30584387 PMCID: PMC6287516 DOI: 10.2147/dnnd.s138835] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Bowel dysfunction in patients with multiple sclerosis (MS) is highly prevalent. Constipation and fecal incontinence can coexist and alternate, impacting on the patient's quality of life and social interactions, as well as burdening the caregivers. The cost for the health care providers is also significant, with increased number of hospital admissions, treatment-related costs, and hospital appointments. The origin is multifactorial, and includes alteration of neurological pathways, polypharmacy, behavioral elements, and ability to access the toilet. Every patient with MS should be sensitively questioned about bowel function, and red flag symptoms should prompt adequate investigations. Manipulation of life style factors and establishment of a bowel regime should be attempted in the first place, and if this fails, other measures such as biofeedback and transanal irrigation should be included. A stoma can improve quality of life, and is not necessarily a last-ditch option. Antegrade colonic enemas can also be an effective option, whilst neuromodulation has not proved its role yet. Effective treatment of bowel dysfunction improves quality of life, reduces incidence of urinary tract infection, and reduces health care costs.
Collapse
Affiliation(s)
- Giuseppe Preziosi
- Gastro-Intestinal Physiology Unit, University College London Hospital, London, UK,
| | - Ayeshah Gordon-Dixon
- Gastro-Intestinal Physiology Unit, University College London Hospital, London, UK,
| | - Anton Emmanuel
- Gastro-Intestinal Physiology Unit, University College London Hospital, London, UK,
| |
Collapse
|
9
|
Cotterill N, Sullivan A, Norton C, Wilkins A, Weir I, Kilonzo M, Drake MJ. Conservative interventions for urinary or faecal incontinence, or both, in adults with multiple sclerosis. Cochrane Database Syst Rev 2018. [DOI: 10.1002/14651858.cd013150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Nikki Cotterill
- North Bristol NHS Trust; Bristol Urological Institute; Southmead Hospital Bristol UK BS10 5NB
- CLAHRC West; The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West) at University Hospitals Bristol NHS Foundation Trust, UK; 9th Floor, Whitefriars Lewins Mead Bristol UK BS1 2NT
- University of the West of England; Centre for Health and Clinical Research, Faculty of Health and Applied Sciences; Blackberry Hill Bristol UK BS16 1DD
| | - Amanda Sullivan
- North Bristol NHS Trust; Department of Physiotherapy; Southmead Hospital, Southmead Road Bristol UK BS10 5NB
| | - Christine Norton
- King's College London; Adult Nursing, Florence Nightingale Faculty of Nursing Midwifery and Palliative Care; 57 Waterloo Road London UK SE1 8WA
| | - Alastair Wilkins
- North Bristol NHS Trust; Bristol and Avon Multiple Sclerosis Unit/Clinical Neurosciences; Southmead Hospital, Southmead Road Bristol UK BS10 5NB
| | - Iain Weir
- University of West of England; Department of Engineering, Design and Mathematics; Coldharbour Lane Bristol UK BS16 1QY
| | - Mary Kilonzo
- University of Aberdeen; Health Economics Research Unit; Aberdeen UK AB25 2ZD
| | - Marcus J Drake
- University of Bristol; School of Clinical Sciences; Bristol UK BS10 5NB
| |
Collapse
|
10
|
Marola S, Ferrarese A, Gibin E, Capobianco M, Bertolotto A, Enrico S, Solej M, Martino V, Destefano I, Nano M. Anal sphincter dysfunction in multiple sclerosis: an observation manometric study. Open Med (Wars) 2016; 11:509-517. [PMID: 28352843 PMCID: PMC5329875 DOI: 10.1515/med-2016-0088] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 09/06/2016] [Indexed: 11/15/2022] Open
Abstract
Constipation, obstructed defecation, and fecal incontinence are frequent complaints in multiple sclerosis. The literature on the pathophysiological mechanisms underlying these disorders is scant. Using anorectal manometry, we compared the anorectal function in patients with and without multiple sclerosis. 136 patients referred from our Center for Multiple Sclerosis to the Coloproctology Outpatient Clinic, between January 2005 and December 2011, were enrolled. The patients were divided into four groups: multiple sclerosis patients with constipation (group A); multiple sclerosis patients with fecal incontinence (group B); non-multiple sclerosis patients with constipation (group C); non-multiple sclerosis patients with fecal incontinence (group D). Anorectal manometry was performed to measure: resting anal pressure; maximum squeeze pressure; rectoanal inhibitory reflex; filling pressure and urge pressure. The difference between resting anal pressure before and after maximum squeeze maneuvers was defined as the change in resting anal pressure calculated for each patient. RESULTS Group A patients were noted to have greater sphincter hypotonia at rest and during contraction compared with those in group C (p=0.02); the rectal sensitivity threshold was lower in group B than in group D patients (p=0.02). No voluntary postcontraction sphincter relaxation was observed in either group A or group B patients (p=0.891 and p=0.939, respectively). CONCLUSIONS The decrease in the difference in resting anal pressure before and after maximum squeeze maneuvers suggests post-contraction sphincter spasticity, indicating impaired pelvic floor coordination in multiple sclerosis patients. A knowledge of manometric alterations in such patients may be clinically relevant in the selection of patients for appropriate treatments and for planning targeted rehabilitation therapy.
Collapse
Affiliation(s)
- Silvia Marola
- University of Turin, Department of Oncology, School of Medicine, Teaching Hospital “San Luigi Gonzaga”, Section of General Surgery, Orbassano, Turin, Italy
| | - Alessia Ferrarese
- University of Turin, Section of General Surgery, San Luigi Gonzaga Teaching Hospital, Regione Gonzole 10, 10043 Orbassano, Turin, Italy
| | - Enrico Gibin
- University of Turin, Department of Oncology, School of Medicine, Teaching Hospital “San Luigi Gonzaga”, Section of General Surgery, Orbassano, Turin, Italy
| | - Marco Capobianco
- University of Turin, Department of Oncology, School of Medicine, Teaching Hospital “San Luigi Gonzaga”, Section of General Surgery, Orbassano, Turin, Italy
| | - Antonio Bertolotto
- University of Turin, Department of Oncology, School of Medicine, Teaching Hospital “San Luigi Gonzaga”, Section of General Surgery, Orbassano, Turin, Italy
| | - Stefano Enrico
- University of Turin, Department of Oncology, School of Medicine, Teaching Hospital “San Luigi Gonzaga”, Section of General Surgery, Orbassano, Turin, Italy
| | - Mario Solej
- University of Turin, Department of Oncology, School of Medicine, Teaching Hospital “San Luigi Gonzaga”, Section of General Surgery, Orbassano, Turin, Italy
| | - Valter Martino
- University of Turin, Department of Oncology, School of Medicine, Teaching Hospital “San Luigi Gonzaga”, Section of General Surgery, Orbassano, Turin, Italy
| | - Ines Destefano
- University of Turin, Department of Oncology, School of Medicine, Teaching Hospital “San Luigi Gonzaga”, Section of General Surgery, Orbassano, Turin, Italy
| | - Mario Nano
- University of Turin, Department of Oncology, School of Medicine, Teaching Hospital “San Luigi Gonzaga”, Section of General Surgery, Orbassano, Turin, Italy
| |
Collapse
|
11
|
Anorectal biofeedback for neurogenic bowel dysfunction in incomplete spinal cord injury. Spinal Cord 2016; 54:1132-1138. [DOI: 10.1038/sc.2016.67] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 03/24/2016] [Accepted: 03/24/2016] [Indexed: 11/08/2022]
|
12
|
Pintér A, Cseh D, Sárközi A, Illigens BM, Siepmann T. Autonomic Dysregulation in Multiple Sclerosis. Int J Mol Sci 2015; 16:16920-52. [PMID: 26213927 PMCID: PMC4581177 DOI: 10.3390/ijms160816920] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 07/13/2015] [Accepted: 07/20/2015] [Indexed: 02/07/2023] Open
Abstract
Multiple sclerosis (MS) is a chronic, progressive central neurological disease characterized by inflammation and demyelination. In patients with MS, dysregulation of the autonomic nervous system may present with various clinical symptoms including sweating abnormalities, urinary dysfunction, orthostatic dysregulation, gastrointestinal symptoms, and sexual dysfunction. These autonomic disturbances reduce the quality of life of affected patients and constitute a clinical challenge to the physician due to variability of clinical presentation and inconsistent data on diagnosis and treatment. Early diagnosis and initiation of individualized interdisciplinary and multimodal strategies is beneficial in the management of autonomic dysfunction in MS. This review summarizes the current literature on the most prevalent aspects of autonomic dysfunction in MS and provides reference to underlying pathophysiological mechanisms as well as means of diagnosis and treatment.
Collapse
Affiliation(s)
- Alexandra Pintér
- Institute of Human Physiology and Clinical Experimental Research, Faculty of Medicine, Semmelweis University, Budapest 1085, Hungary.
- Center for Clinical Research and Management Education, Division of Health Care Sciences, Dresden International University, Dresden 01067, Germany.
| | - Domonkos Cseh
- Institute of Human Physiology and Clinical Experimental Research, Faculty of Medicine, Semmelweis University, Budapest 1085, Hungary.
| | - Adrienn Sárközi
- Institute of Human Physiology and Clinical Experimental Research, Faculty of Medicine, Semmelweis University, Budapest 1085, Hungary.
| | - Ben M Illigens
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA.
| | - Timo Siepmann
- Center for Clinical Research and Management Education, Division of Health Care Sciences, Dresden International University, Dresden 01067, Germany.
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden 01307, Germany.
- Department of Psychotherapy and Psychosomatic Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden 01307, Germany.
| |
Collapse
|
13
|
Dandin Ö, Akpak YK, Karakaş DÖ, Hazer B, Ergin T, Dandinoğlu T, Teomete U. A rare condition of anorectal dysfunction in a patient with multiple sclerosis: Coexistence of faecal incontinence and mechanical constipation: Report of case. Int J Surg Case Rep 2014; 5:1091-4. [PMID: 25460483 PMCID: PMC4275814 DOI: 10.1016/j.ijscr.2014.11.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 11/07/2014] [Accepted: 11/08/2014] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Multiple sclerosis is a chronic demyelinating neurological disease and causing a variety of neurological symptoms, including discomfort of anorectal function. Constipation and faecal incontinence present as anorectal dysfunction in MS and anal manometry, colonic transit time, electromyography, and defecography can be used for assessment. PRESENTATION OF CASE We presented a thirty-three years old woman with rare condition of anorectal dysfunction in multiple sclerosis. Anal manometry, defecography were done, and synchronously anal incontinence and mechanical constipation due to rectocele and anismus were detected in this patient. DISCUSSION Although anal incontinence and constipation are seen often in patients with multiple sclerosis, in the literature, coexistence of animus, rectocele and anal incontinence are quite rare. CONCLUSION Defecography and anal manometry are useful diagnostic methods for demonstration of anorectal dysfuntions in patients with MS.
Collapse
Affiliation(s)
- Özgür Dandin
- Bursa Military Hospital, Department of General Surgery, Bursa, Turkey
| | - Yaşam Kemal Akpak
- Ankara Mevki Military Hospital, Department of Obstetrics and Gynecology, Ankara, Turkey.
| | | | - Batuhan Hazer
- Kasımpaşa Military Hospital, Department of General Surgery, Istanbul, Turkey
| | - Tuncer Ergin
- Bursa Military Hospital, Department of Radiology, Bursa, Turkey
| | - Taner Dandinoğlu
- Bursa Military Hospital, Department of Physical Medicine and Rehabilitation, Bursa, Turkey
| | - Uygar Teomete
- Miami University Jackson Memorial Hospital, Department of Radiology, FL, USA
| |
Collapse
|
14
|
Lee D, Arora G. Medical management of fecal incontinence in challenging populations: a review. Clin Colon Rectal Surg 2014; 27:91-8. [PMID: 25320567 DOI: 10.1055/s-0034-1384661] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Fecal incontinence (FI) is a common and growing problem in the United States. Although there are multiple emerging novel interventions for the treatment of FI, the mainstay of initial therapy remains medical management. In this article, we review the available literature on the medical management of FI, with a special focus on patients with multiple sclerosis, diabetes mellitus, and the elderly.
Collapse
Affiliation(s)
- David Lee
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Gaurav Arora
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas ; Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| |
Collapse
|
15
|
Abstract
BACKGROUND Constipation and fecal incontinence affect 68% of patients with multiple sclerosis, but management is empirical. Transanal irrigation has been used successfully in patients with neurogenic bowel dysfunction. OBJECTIVE The aim of this study was to evaluate the effect of transanal irrigation on the bowel symptoms and general health status in these patients and the characteristics of those that had successful treatment and to obtain data for power calculations necessary for future randomized controlled studies. DESIGN This was a prospective observational study in which pre- and posttreatment questionnaires (bowel symptoms and health status) were compared. Patients for whom treatment resulted in at least 50% improvement in bowel symptoms were considered responders. Baseline variables including anorectal physiology tests and rectal compliance were compared between responders and nonresponders. SETTINGS This study was conducted at a specialist neurogastroenterology clinic, tertiary referral center. PATIENTS Included were 30 patients who had multiple sclerosis and constipation, fecal incontinence, or both. INTERVENTION Transanal irrigation was performed. MAIN OUTCOME MEASURES The primary outcomes measured were the Wexner Constipation and Wexner Incontinence scores. The secondary outcomes was the SF-36 health survey. All scores were recorded before and after 6 weeks of treatment. RESULTS At 6 weeks posttreatment, the Wexner Constipation score significantly improved (12 (8.75/16) pretreatment vs 8 (4/12.5) posttreatment, p = 0.001), as well as the Wexner Incontinence score (12 (4.75/16) pretreatment vs 4 (2/8) posttreatment, p < 0.001). The SF-36 score did not improve significantly (51.3 ± 7.8 pretreatment vs 50.4 ± 7.8 posttreatment, p = 0.051). Sixteen patients were responders and had higher baseline Wexner Incontinence scores (14 (11/20) responders vs 9 (4/15) nonresponders, p = 0.038) and SF-36 (53.9 ± 6.3 responders vs 47.9 ± 7.8 nonresponders, p = 0.027), as well as greater maximum tolerated volume to rectal balloon distension (310 (220/320) mL responders vs 168 (108/305) mL nonresponders, p = 0.017) and rectal compliance (15.2 (14.5/17.2) mL/mmHg responders vs 9.2 (7.2/15.3) mL/mmHg nonresponders, p = 0.019). LIMITATIONS This study was limited by its small sample size and the lack of control group with alternative treatment. CONCLUSIONS Transanal irrigation is effective to treat bowel symptoms in patients with multiple sclerosis. Responders (53%) had higher baseline incontinence symptoms and better perception of their health, as well as a more capacious and compliant rectum.
Collapse
|
16
|
Nusrat S, Gulick E, Levinthal D, Bielefeldt K. Anorectal dysfunction in multiple sclerosis: a systematic review. ISRN NEUROLOGY 2012; 2012:376023. [PMID: 22900202 PMCID: PMC3414061 DOI: 10.5402/2012/376023] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Accepted: 05/28/2012] [Indexed: 12/13/2022]
Abstract
Constipation and fecal incontinence are common in patients with neuromuscular diseases. Despite their high prevalence and potential impact on overall quality of life, few studies have addressed anorectal dysfunction in patients with multiple sclerosis (MS). The goal of this paper is to define the prevalence, pathophysiology, impact, and potential treatment of constipation and incontinence in MS patients. Methods. The PubMed database was searched for English language publications between January 1973 and December 2011. Articles were reviewed to assess the definition of the study population, duration, type and severity of MS, sex distribution, prevalence, impact, results of physiologic testing, and treatments. Results. The reported prevalence of constipation and fecal incontinence ranged around 40%. Anorectal dysfunction significantly affected patients with nearly 1 in 6 patients limiting social activities or even quitting work due to symptoms. Caregivers listed toileting as a common and significant burden. The only randomized controlled trial showed a marginal improvement of constipation with abdominal massage. All other reports lacked control interventions and only demonstrated improvement in individuals with milder symptoms. Conclusion. Anorectal dysfunction is a common manifestation in MS that significantly affects quality of life. Therapies are at best moderately effective and often cumbersome, highlighting the need for simple and more helpful interventions.
Collapse
Affiliation(s)
- Sanober Nusrat
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15217, USA
| | | | | | | |
Collapse
|
17
|
Awad RA. Neurogenic bowel dysfunction in patients with spinal cord injury, myelomeningocele, multiple sclerosis and Parkinson’s disease. World J Gastroenterol 2011; 17:5035-48. [PMID: 22171138 PMCID: PMC3235587 DOI: 10.3748/wjg.v17.i46.5035] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2011] [Revised: 06/20/2011] [Accepted: 06/27/2011] [Indexed: 02/06/2023] Open
Abstract
Exciting new features have been described concerning neurogenic bowel dysfunction, including interactions between the central nervous system, the enteric nervous system, axonal injury, neuronal loss, neurotransmission of noxious and non-noxious stimuli, and the fields of gastroenterology and neurology. Patients with spinal cord injury, myelomeningocele, multiple sclerosis and Parkinson’s disease present with serious upper and lower bowel dysfunctions characterized by constipation, incontinence, gastrointestinal motor dysfunction and altered visceral sensitivity. Spinal cord injury is associated with severe autonomic dysfunction, and bowel dysfunction is a major physical and psychological burden for these patients. An adult myelomeningocele patient commonly has multiple problems reflecting the multisystemic nature of the disease. Multiple sclerosis is a neurodegenerative disorder in which axonal injury, neuronal loss, and atrophy of the central nervous system can lead to permanent neurological damage and clinical disability. Parkinson's disease is a multisystem disorder involving dopaminergic, noradrenergic, serotoninergic and cholinergic systems, characterized by motor and non-motor symptoms. Parkinson's disease affects several neuronal structures outside the substantia nigra, among which is the enteric nervous system. Recent reports have shown that the lesions in the enteric nervous system occur in very early stages of the disease, even before the involvement of the central nervous system. This has led to the postulation that the enteric nervous system could be critical in the pathophysiology of Parkinson's disease, as it could represent the point of entry for a putative environmental factor to initiate the pathological process. This review covers the data related to the etiology, epidemiology, clinical expression, pathophysiology, genetic aspects, gastrointestinal motor dysfunction, visceral sensitivity, management, prevention and prognosis of neurogenic bowel dysfunction patients with these neurological diseases. Embryological, morphological and experimental studies on animal models and humans are also taken into account.
Collapse
|
18
|
Quigley EMM, O'Mahony S, Heetun Z. Motility disorders in the patient with neurologic disease. Gastroenterol Clin North Am 2011; 40:741-64. [PMID: 22100115 DOI: 10.1016/j.gtc.2011.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Gastrointestinal symptoms are common in the patient with chronic neurologic disease and may loom large in terms of impact on quality of life and on nutrition and mobility. A knowledge of the range of gastrointestinal disorders associated with a given neurologic disease, together with an understanding of the risks and benefits of various therapeutic options and approaches, should aid gastroenterologists in their efforts to contribute to the care of these patients. In most instances a multidisciplinary team (neurologist/neurosurgeon, gastroenterologist, nutritionist, therapist, specialist nurse) aware of the wishes and needs of the family and their carers and mindful of the nature and the natural history of the underlying disease process are best placed to assess and manage these problems.
Collapse
Affiliation(s)
- Eamonn M M Quigley
- Department of Medicine, Alimentary Pharmabiotic Centre, University College Cork, Cork, Ireland.
| | | | | |
Collapse
|
19
|
Abstract
BACKGROUND Bowel symptoms are common in patients with multiple sclerosis, but current treatment is empirical. OBJECTIVE This study aimed to identify effect of biofeedback on bowel symptoms, mood, and anorectal physiology in patients with multiple sclerosis. DESIGN This was a prospective observational study: the amount of change between pre- and posttreatment values of outcome measures was compared and analyzed. Responders were considered to be patients who demonstrated an improvement greater than or equal to the 25th percentile of the change in bowel score. Comparison between responders and nonresponders was performed. SETTINGS This investigation was conducted at a neurogastroenterology clinic, tertiary referrals center. PATIENTS Thirty-nine patients with multiple sclerosis and constipation and/or fecal incontinence were included in the study. INTERVENTION Patients were given bowel biofeedback therapy. MAIN OUTCOME MEASURES The primary outcome measures were the Wexner Constipation and Wexner Incontinence scores. The secondary outcome measures were hospital anxiety and depression scores and anorectal physiology parameters. RESULTS Data are reported as median and interquartile ranges. After biofeedback there was significant improvement in Wexner Constipation (12 (5-19) pretreatment vs 8 (4-14) posttreatment, P = .001), Wexner Incontinence (12 (3-15) pretreatment vs 4 (2-10) posttreatment, P < .001) and hospital depression scores (7 (3-11) pretreatment vs 5 (3-10) posttreatment, P = .015). The 5-second endurance squeeze pressure was also improved (21 (11-54) mmHg pretreatment vs 43 (26-59) mmHg posttreatment, P = .001). Posttreatment change of Wexner Constipation was -2(-5/0), and of Wexner Incontinence was -3(-9/0) ("-" indicates improvement). Therefore, those patients who had a reduction of at least 5 points in the Wexner Constipation score and/or of at least 9 points in the Wexner Incontinence score were considered responders (18 patients, 46%). They showed a greater improvement of only 5-second endurance squeeze pressure (23.5 (7.5/32.75) mmHg responders vs 4 (-6/20) mmHg nonresponders, P = .008); no difference was observed in the comparison of baseline variables with nonresponders. Significant negative relationship existed between the change in the Wexner Constipation score (-2 (-5/0)) and the pretreatment Wexner Constipation score (12 (5/19), β = -0.463, P < .001), and the change in the Wexner Incontinence score (-3 (-9/0)) with the pretreatment Wexner Incontinence score (12 (3/15), β = -0.590, P < .001). So, the higher the initial bowel symptom score, the greater the improvement. LIMITATIONS This study was limited by the lack of a control group. CONCLUSIONS Biofeedback improves bowel symptoms, depression, and 5-second endurance squeeze pressure in patients with multiple sclerosis.
Collapse
|
20
|
Guinet A, Jousse M, Damphousse M, Hubeaux K, Le Breton F, Sheikh Ismael S, Amarenco G. Modulation of the rectoanal inhibitory reflex (RAIR): qualitative and quantitative evaluation in multiple sclerosis. Int J Colorectal Dis 2011; 26:507-13. [PMID: 21193913 DOI: 10.1007/s00384-010-1109-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/03/2010] [Indexed: 02/04/2023]
Abstract
BACKGROUND Rectoanal inhibitory reflex (RAIR) is a physiological modulated reflex involved in anorectal continence and defined by a relaxation of internal anal sphincter following rectal distension. Its existence depends on intramural autonomic ganglions and its modulation on the integrity of the autonomic nervous system (ANS). AIMS The aim of this study was to analyse RAIR modulation in terms of amplitude and duration in multiple sclerosis (MS) patients. METHODS Twenty-one patients with MS and 40 control patients had anorectal manometry. Qualitative assessment (presence or absence) of RAIR was evaluated together with its modulation in amplitude and in duration. RESULTS All patients had present RAIR for each volume of rectal distension (10-50 ml). Seven patients (33.3%) in the MS group had abnormal RAIR modulation in amplitude (odds ratio (OR) = 2.78, compared to control group, p = 0.11). Nine patients (42.9%) in the MS group had abnormal RAIR modulation in duration (p = 0.14, OR = 2.54, compared to control group). Alteration of RAIR modulation was not correlated with Expanded Disability Status Scale, faecal incontinence and constipation (p > 0.05). Course of MS (relapsing-remitting MS or secondary progressive form) seems to be correlated to alteration of modulation in amplitude and in duration (OR = 1.31 and 1.07). CONCLUSION Even if our results do not have the required statistical significance (p > 0.05), they are interesting. If RAIR is always present in MS, its modulation seems to be altered. A hypothesis for this lack of RAIR modulation could be the alteration of ANS, often involved in MS besides somatic nervous system lesions.
Collapse
Affiliation(s)
- Amandine Guinet
- Service de Neuro-Urologie et Explorations Périnéales, Unité de Recherche Er6 UPMC, Université Pierre et Marie Curie Paris VI, Hôpital Tenon, APHP, 4, Rue de Chine, 75970, Paris Cedex 20, France.
| | | | | | | | | | | | | |
Collapse
|
21
|
Comparison of Prevalence, Related Medical History, Symptoms, and Interventions Regarding Bowel Dysfunction in Persons With Multiple Sclerosis. J Neurosci Nurs 2010. [DOI: 10.1097/jnn.0b013e3181e26bfb] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
22
|
Donzé C, Hautecoeur P. [Urinary, sexual, and bowel disorders in early-stage multiple sclerosis]. Rev Neurol (Paris) 2009; 165 Suppl 4:S148-55. [PMID: 19361680 DOI: 10.1016/s0035-3787(09)72127-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Most multiple sclerosis (MS) patients experience some bladder, sexual, and/or bowel dysfunction during the course of the disease, which has been closely associated with the quality-of-life scores, including in patients with otherwise low disability. This underlines the need for identifying and treating these problems. Bladder dysfunction produces symptoms of urgency, frequency, and urge incontinence (due to bladder over activity and incomplete emptying), and is found in up to 80% of patients with MS. These symptoms occur in the early stage of the disease and require screening and rigorous monitoring. For many patients, treatment is effective and has been shown to reduce the risks of urologic complications, improve levels of continence, and enhance the patient's quality of life. Sexual disturbances are also present from the beginning and have and greatly influence the quality of life of the MS patient. The findings in the literature show substantial evidence that people with MS experience high levels of sexual dysfunction, most of them with hypoactive sexual behavior often associated with dissatisfaction in the relationship. The most common problems in women are lack of sexual interest and decreased libido, often with problems in orgasmic capacity, while men report erectile dysfunction and also lack of sexual interest. Unlike bladder dysfunction, there have been rather limited advances in the treatment of fecal incontinence and constipation specifically for patients with MS, despite a prevalence of up to 50%. Until now, the management of these problems has been empirical, with a lack of evaluated therapeutic regimes. Biofeedback retraining is an effective treatment in some patients with MS complaining of constipation or fecal incontinence. A response is more likely in patients with limited disability and a nonprogressive disease course. Since treatments and preventive strategies can manage many of these problems, we suggest increasing the focus on these aspects of the disease when consulting patients, including at early stages.
Collapse
Affiliation(s)
- C Donzé
- Service de médecine physique et réadaptation fonctionnelle, Groupe Hospitalier de l'Institut Catholique de Lille, Rue du grand but, BP387, 59462 Lomme cedex, France.
| | | |
Collapse
|