Japanese Practice Guidelines for Fecal Incontinence Part 1-Definition, Epidemiology, Etiology, Pathophysiology and Causes, Risk Factors, Clinical Evaluations, and Symptomatic Scores and QoL Questionnaire for Clinical Evaluations-English Version

Diagnostic tools for fecal incontinence: Scoring systems are the crucial first step

The main aim of this editorial is to comment on the recent article published by Garg et al in the World Journal of Gastroenterology 2023; 29: 4593-4603. This original research presents a new scoring system for fecal incontinence. Fecal incontinence is a chronic disease with a severe impact on the quality of life of the patients. Substantial social stigmatization often leads to significant underreporting of the condition even during visits to a specialist and could lead to further mismanagement or non-existent management of the disease. An important fact is that patients are often unable to describe their condition when not asked precisely defined questions. This problem is partially resolved by scoring questionnaires. Several scoring systems are commonly used; however, each of them has their shortcomings. For example, the absence of different kinds of leakage besides flatus and stool could further lead to underscoring the incontinence severity. Therefore, there has long been a call for a more precise scoring system. The correct identification of the presence and severity of fecal incontinence is paramount for further diagnostic approach and for choosing the appropriate therapy option. This editorial describes fecal incontinence, its effect on quality of life in general and further evaluates the diagnostic approach with a particular focus on symptom scoring systems and their implications for clinical practice.

Prevalence of Double Incontinence and Lower Urinary Tract Symptoms in Patients with Fecal Incontinence: A Single-center Observational Study

Objectives

Double incontinence (DI), which is the co-occurrence of fecal incontinence (FI) and urinary incontinence (UI), increases with age and has a greater negative impact on the quality of life (QOL) than either incontinence alone. We aimed to assess lower urinary tract symptoms (LUTS) in patients with FI to elucidate the prevalence and characteristics of DI.

Methods

This study enrolled consecutive patients who visited our hospital with FI symptoms. FI was evaluated using the Cleveland Clinic Florida Fecal Incontinence Score (CCFIS). LUTS were assessed using the International Prostate Symptom Score (IPSS), QOL score (IPSS-QOL) and Overactive Bladder Symptom Score (OABSS).

Results

This study evaluated 140 patients (96 women [mean age: 70.7 years] and 44 men [mean age: 74.4 years]). The mean IPSS was significantly higher in men than in women (12.0 vs. 7.5, p = 0.003). A positive correlation was found between IPSS and CCFIS in women (r = 0.256, p = 0.012) but not in men. For both sexes, the older group (aged ≥70 years) had higher OABSS scores and more urge UI instances than the younger group (aged ≤69 years). Of the 140 patients with FI, 78 (55.7%) had DI, and DI was more common in women than in men (63.5% vs. 38.6%, p = 0.006).

Conclusions

The characteristics of LUTS and UI in patients with FI were comparable to those in the general population for both sexes; however, the prevalence of DI was much higher among patients with FI than that in the general population.

Novel Nonablative Radiofrequency Approach for the Treatment of Anal Incontinence: A Phase 1 Clinical Trial

OBJECTIVE

We aimed to describe the action, impact on quality of life, and side effects of perianal nonablative radiofrequency (RF) application in the treatment of anal incontinence (AI) in women.

METHODS

This was a pilot, randomized clinical trial conducted between January and October 2016. We enrolled women who consecutively attended the Attention Center of the Pelvic Floor (CAAP) with complaints of AI for more than six months. Nonablative RF was applied to the perianal region of the participants using Spectra G2 (Tonederm®, Rio Grande do Sul, Brazil). The reduced or complete elimination of the need for protective undergarments (diapers and absorbents) was considered a partial therapeutic response.

RESULTS

Nine participants reported treatment satisfaction, while one reported dissatisfaction with the nonablative RF treatment of AI based on the Likert scale. No patient interrupted treatment sessions because of adverse effects, although adverse effects occurred in six participants. However, the clinical and physical examination of the participants with burning sensations showed no hyperemia or mucosal lesions.

CONCLUSIONS

This study showed a promising reduction of fecal loss, participant satisfaction with treatment, and improved lifestyle, behavior, and depression symptoms with minimal adverse effects.

Association of poor oral health status and faecal incontinence in patients with dysphagia: A cross-sectional analysis from the Sarcopenic Dysphagia Database

BACKGROUND

Poor oral health status may alter oral and gut microbiota. Previous studies have shown that poor oral health can exacerbate gut inflammation. Therefore, poor oral health status may be related to faecal incontinence via changes in the gut.

OBJECTIVE

To investigate the association between poor oral health status and faecal incontinence in inpatients with dysphagia.

METHODS

This multicentre cross-sectional study included 423 patients (mean age 79.8 ± 11.5 years, 48.2% female) with dysphagia. Oral health status was assessed at each facility using the Oral Health Assessment Tool (OHAT) or the Revised Oral Assessment Guide (ROAG). Poor oral health status was defined as an OHAT score of ≥3 or a ROAG score of ≥13. A multivariate logistic model was used to analyse the association between poor oral health status and faecal incontinence.

RESULTS

A total of 351 (83.0%) patients had poor oral health and 97 (22.7%) had faecal incontinence. Patients with poor oral health status had a higher proportion of faecal incontinence than those with normal oral health status (25.4% vs. 11.1%, p = .009). A multivariate logistic model revealed an association between faecal incontinence and poor oral health status (adjusted odds ratio = 2.501, 95% confidence interval = 1.065-5.873, p = .035).

CONCLUSIONS

Poor oral health status assessed by OHAT or ROAG in inpatients with dysphagia may adversely affect faecal incontinence. Further studies are needed to determine the causal relationship between poor oral health status and faecal incontinence.

Improvement in sarcopenia is positively associated with recovery of independence in urination and defecation in patients undergoing rehabilitation after a stroke

OBJECTIVES

This study aimed to examine the association between improvement in sarcopenia and the recovery of urinary and defecatory independence in patients undergoing convalescent rehabilitation.

METHODS

A retrospective cohort study was conducted of 849 older inpatients after a stroke. Of these, patients with sarcopenia and dependent voiding movements were targeted. Sarcopenia was assessed according to the Asian Working Group for Sarcopenia 2019, and diagnosed using handgrip strength (HGS) and skeletal muscle-mass index. Outcomes were sphincter control items of the Functional Independence Measure (FIM) at the time of discharge: urinary (FIM-Bladder) and defecation (FIM-Bowel). A score of six or higher was considered independent. A logistic regression analysis was used to determine whether sarcopenia improvement was associated with outcomes.

RESULTS

Of the patients recruited, 151 were diagnosed with sarcopenia at baseline, of whom patients dependent in urination (109 patients) and defecation (102 patients) were included in the analysis. The multivariate analysis showed that improvement in sarcopenia (odds ratio [OR]: 3.28; 95% confidence interval [CI],1.01-10.70; P = 0.048) and HGS (OR: 6.25; 95% CI, 1.45-26.90; P = 0.014) were independently associated with FIM-Bladder at the time of discharge. Improvement in HGS (OR: 4.33; 95% CI, 0.99-18.90; P = 0.048) was independently associated with FIM-Bowel at the time of discharge CONCLUSIONS: Improvement in sarcopenia and muscle strength during hospitalization may have a positive effect on urinary independence in stroke patients undergoing convalescent rehabilitation, and improvement in muscle strength may have a positive effect on defecation independence. Multidisciplinary sarcopenia treatment should be implemented in addition to conventional rehabilitation for these patients.

Injection of aluminum potassium sulfate and tannic acid in the treatment of fecal incontinence: a single-center observational study

PURPOSE

Perianal injection of bulking agents is an attractive treatment option for patients with mild to moderate fecal incontinence (FI). Various bulking agents have been used for injection therapy, but the optimal injection materials and methods are yet to be standardized. This study aimed to evaluate the effects of injection therapy using aluminum potassium sulfate and tannic acid (ALTA) in the management of FI.

METHODS

This study included consecutive patients who underwent ALTA injection therapy for FI at our institution. The procedure was performed with the patient in the jackknife position, under caudal epidural anesthesia. The procedure consisted of a 4-step injection to the 3 main cushions and a multipoint injection to the remaining submucosa of the anal canal.

RESULTS

Seventy-seven patients (mean age, 76 years) were enrolled in the study. The mean Cleveland Clinic incontinence score of 11.9 ± 4.1 at baseline significantly improved to 7.3 ± 5.2 at 3 months following treatment. The mean maximal resting pressure also increased significantly 3 months after the intervention. Postoperative complications were observed in 3 patients (3.9%), and all events were mild. The mean duration of postoperative follow-up was 17.5 months. The cumulative recurrence-free rate at 3 years was 72.4%.

CONCLUSION

ALTA injection for FI is safe, easy to perform, and provides reasonable mid-term outcomes. Moreover, concomitant anorectal diseases that may be contraindicated by other injectable bulking agents could be treated simultaneously. Therefore, ALTA injection is a promising alternative in the absence of other injectable agents.

Simple Anal Reinforcement with Anal Encirclement Using an Artificial Ligament in Patients with fecal Incontinence: A Single-center Observational Study

Objectives:

Surgical repair of anal sphincter defects in patients with fecal incontinence (FI) has been associated with excellent or good short-term results; however, its benefits have been shown to deteriorate over long-term follow-up. When sphincteroplasty fails or is not feasible, the subsequent surgical options are limited. This study aimed to evaluate the efficacy of anal encirclement using the Leeds-Keio ligament in patients with FI.

Methods:

The inclusion criteria for the procedure were failure of or unsuitability for sphincteroplasty and the presence of a patulous anus (diameter, ≥35 mm). The artificial ligament was routed outside the external anal sphincter at the depth of the middle anal canal under caudal epidural anesthesia.

Results:

Fourteen patients (mean age, 79.4 years; 8 females) with FI were included. Of these, seven (50%) showed a ≥50% reduction in the Cleveland Clinic Florida Fecal Incontinence Score (CCFIS). The mean CCFIS of 13.6 at baseline significantly improved to 7.9 3 months after surgery. The mean maximal anal resting pressure significantly increased from 16.8 mmHg to 22.6 mmHg. Postoperatively, temporary fecal impaction was observed in one patient (7%). None of the cases required removal of the artificial ligament or additional operative interventions for FI during the mean follow-up period of 31.9 months.

Conclusions:

Anal encirclement using the Leeds-Keio ligament was technically simple and safe and achieved good short-term outcomes. Therefore, this technique appears to be a simple solution for sphincter defects and may become an important surgical option for patients with FI and a patulous anus.

Quality and clinical applicability of recommendations for incontinence-associated dermatitis: A systematic review of guidelines and consensus statements

AIMS AND OBJECTIVES

The aim of this study was to assess methodological quality of all currently available guidelines and consensus statements for IAD using the Appraisal of Guidelines, Research and Evaluation (AGREE) II and the AGREE Recommendation Excellence (AGREE-REX) instruments.

BACKGROUND

Globally, incontinence-associated dermatitis (IAD) is a significant health challenge. IAD is a complex healthcare problem that reduces quality of life of patients, increases healthcare costs and prolongs hospital stays. Several guidelines and consensus statements are available for IAD. However, the quality of these guidelines and consensus statements remains unclear.

DESIGN

A systematic review of guidelines and consensus statements.

METHODS

Our study was undertaken using PRISMA guidelines. We searched seven electronic databases. Guidelines and consensus statements had to be published in English, Chinese or German languages. Five independent reviewers assessed the methodological quality of guidelines and consensus statements using the AGREE II and AGREE-REX instruments. Mean with standard deviation (SD) and median with interquartile range (IQR) were calculated for descriptive analyses. We generated bubble plots to describe the assessment results of each domain of each guideline and consensus statement.

RESULTS

We included ten guidelines and consensus statements. The NICE guidelines, obtained the highest scores, fulfilled 86.11%-98.61% of criteria in AGREE II and 76.67%-91.11% for AGREE-REX. In the domains 'Stakeholder Involvement' (4.39 ± 1.64), 'Rigor of Development' (3.38 ± 1.86), 'Applicability' (3.62 ± 1.64), 'Editorial Independence' (3.91 ± 2.56) and 'Values and Preferences' (2.98 ± 1.41), the remaining guidelines and consensus statements showed deficiencies.

CONCLUSIONS

Altogether, this study demonstrated that the currently available guidelines and consensus statements for IAD have room for methodological improvement. NICE guidelines on faecal incontinence and urinary incontinence have better quality. Remaining guidelines and consensus statements showed substantial methodological weaknesses, especially the domains of 'Stakeholder Involvement', 'Rigor of Development', 'Applicability', 'Editorial independence' and 'Values and Preferences'. This study was registered on INPLASY. (Registration number: INPLASY202190078).

RELEVANCE TO CLINICAL PRACTICE

The currently available guidelines and consensus statements on IAD have room for methodological improvement.

Efficacy and Safety of the Japanese Herbal Medicine Daikenchuto (DKT) in Elderly Fecal Incontinence Patients: A Prospective Study

Objectives:

Methods:

Results:

Conclusions:

Fecal Incontinence: The Importance of a Structured Pathophysiological Model

Fecal incontinence has an enormous social and economic impact and may significantly impair quality of life. Even though fecal incontinence is a common complaint in (aging) adults, a structured pathophysiological model of the clinical presentations of fecal incontinence is missing in current literature. The most frequent manifestations of fecal incontinence are passive fecal loss, urge incontinence, or mixed fecal incontinence. At our institution, we treat 400 patients per year with defecation disorders, including a significant number of patients with fecal incontinence. On the basis of this experience, we have tried to create a concept that merges current insight in causes and treatment options in a clinically useful algorithm. By applying the system of anamnesis and physical examination described in this article and expanding it with simple additional anorectal examination, in most patients, one can determine the type of fecal incontinence and choose a targeted therapy.

Sarcopenia Is Associated with Fecal Incontinence in Patients with Dysphagia: Implication for Anal Sarcopenia

OBJECTIVES

To examine the relationship between sarcopenia and fecal incontinence in patients with dysphagia.

DESIGN

Cross-sectional study using the Japanese sarcopenic dysphagia database.

SETTING

19 hospitals including 9 acute care hospitals, 8 rehabilitation hospitals, 2 long-term care hospitals, and 1 home visit rehabilitation center.

PARTICIPANTS

460 dysphagic patients, aged 20 years and older.

MEASUREMENTS

Sarcopenia was diagnosed by the 2019 criteria of the Asian Working Group for Sarcopenia. Fecal incontinence was assessed by health care professionals at baseline according to the definition of the Japanese Practice Guidelines for Fecal Incontinence. We examined whether there was a significant difference between the rate of fecal incontinence in patients with/without sarcopenia. Age, sex, type of dwelling, Barthel index, Charlson comorbidity index (CCI), calf circumference, handgrip strength, body mass index, malnourishment, C-reactive protein level, serum albumin level, and delivery of enteral nutrition by nasogastric and/or gastrostomy tube were measured. To examine the relationship between sarcopenia and fecal incontinence, logistic regression analysis was performed with adjustments for age, sex, sarcopenia, CCI, enteral nutrition, and dwelling.

RESULTS

The mean age of patients was 81 ± 10 years. Of the 460 study patients, 404 (88%) patients had sarcopenia and 104 had fecal incontinence (23%). The rate of fecal incontinence was higher in the sarcopenia group than the non-sarcopenia group (25% vs. 7%, P = 0.003). Logistic regression analysis showed that sarcopenia was independently associated with fecal incontinence (odds ratio: 3.114, 95% confidence interval: 1.045, 9.282).

CONCLUSION

The prevalence of fecal incontinence was 23% in patients with dysphagia. Sarcopenia was independently associated with fecal incontinence, which suggests the presence of anal sarcopenia. Defecation control should be assessed in patients with sarcopenia.

Prevalence and Risk Factors of Anal and Fecal Incontinence in Japanese Medical Personnel

Objectives

This study aimed to elucidate the actual state of anal incontinence (AI), fecal incontinence (FI), and the associated factors in Japanese medical personnel.

Methods

A questionnaire was completed by Japanese medical personnel after listening to lectures on AI. AI was defined as involuntary loss of feces or flatus.

Results

A total of 463 persons (mean age, 35.6 years; range, 20-91; male/female/no answer, 132/324/7) participated in the questionnaire. AI occurred in 34.4% of 450 participants (flatus/liquid stool/solid stool: 30.4%/3.6%/0.4%). AI was significantly more prevalent in females (male/female: 15.5%/42.7%, p < 0.001). AI and FI occurred significantly more prevalent in participants aged ≧40 years (p < 0.024). AI was significantly associated with childbirth, frequency of childbirth (more than three times), vaginal delivery, urinary incontinence, the style of urination/defecation, and a history of gynecologic surgery and systemic diseases (p < 0.05). Female gender and age as well as urinary incontinence and inability to defecate separately in female and previous colorectal disease and/or surgery in male were risk factors of AI by multivariate analysis (p < 0.05). FI was correlated with urinary incontinence.

Conclusions

AI and FI occurred in 34.4% and 4.0% of Japanese medical personnel, respectively. Gas incontinence was common in every age group. AI was associated with female gender, higher age group, urinary incontinence, the style of urination and defecation in female, and previous colorectal disease and/or surgery in male. FI was associated with urinary incontinence.

Japanese Practice Guidelines for Fecal Incontinence Part 3 -Surgical Treatment for Fecal Incontinence, Fecal Incontinence in a Special Conditions- English Version

In Japan, the surgical treatment for fecal incontinence (FI) can be performed using minimally invasive surgery, such as anal sphincteroplasty and sacral neuromodulation (SNM), as well as antegrade continence enema (ACE), graciloplasty, and stoma construction. In addition, currently, several other procedures, including biomaterial injection therapy, artificial bowel sphincter (ABS), and magnetic anal sphincter (MAS), are unavailable in Japan but are performed in Western countries. The evidence level of surgical treatment for FI is generally low, except for novel procedures, such as SNM, which was covered by health insurance in Japan since 2014. Although the surgical treatment algorithm for FI has been chronologically modified, it should be sequentially selected, starting from the most minimally invasive procedure, as FI is a benign condition. Injuries to the neural system or spinal cord often cause disorders of the sensory and motor nerves that innervate the anus, rectum, and pelvic floor, leading to the difficulty in controlling bowel movement or FI and/or constipation. FI and constipation are closely associated; when one improves, the other tends to deteriorate. Patients with severe cognitive impairment may present with active soiling, referred to as "incontinence" episodes that occur as a consequence of abnormal behavior, and may also experience passive soiling.

Japanese Practice Guidelines for Fecal Incontinence Part 2-Examination and Conservative Treatment for Fecal Incontinence- English Version

Examination for fecal incontinence is performed in order to evaluate the condition of each patient. As there is no single method that perfectly assesses this condition, there are several tests that need to be conducted. These are as follows: anal manometry, recto anal sensitivity test, pudendal nerve terminal motor latency, electromyogram, anal endosonography, pelvic magnetic resonance imaging (MRI) scan, and defecography. In addition, the mental and physical stress most patients experience during all these examinations needs to be taken into consideration. Although some of these examinations mostly apply for patients with constipation, we hereby describe these tests as tools for the assessment of fecal incontinence. Conservative therapies for fecal incontinence include diet, lifestyle, and bowel habit modification, pharmacotherapy, pelvic floor muscle training, biofeedback therapy, anal insert device, trans anal irrigation, and so on. These interventions have been identified to improve the symptoms of fecal incontinence by determining the mechanisms resulting in firmer stool consistency; strengthening the pelvic floor muscles, including the external anal sphincter; normalizing the rectal sensation; or periodic emptying of the colon and rectum. Among these interventions, diet, lifestyle, and bowel habit modifications and pharmacotherapy can be performed with some degree of knowledge and experience. These two therapies, therefore, can be conducted by all physicians, including general practitioners and other physicians not specializing in fecal incontinence. However, patients with fecal incontinence who did not improve following these initial therapies should be referred to specialized institutions. Contrary to the initial therapies, specialized therapies, including pelvic floor muscle training, biofeedback therapy, anal insert device, and trans anal irrigation, should be conducted in specialized institutions as these require patient education and instructions based on expert knowledge and experience. In general, conservative therapies should be performed for fecal incontinence before surgery because its pathophysiologies are mostly attributed to benign conditions. All Japanese healthcare professionals who take care of patients with fecal incontinence are expected to understand the characteristics of each conservative therapy, so that appropriate therapies will be selected and performed. Therefore, in this chapter, the characteristics of each conservative therapy for fecal incontinence are described.