Correlation Between Mobile-Application Electronic Bowel Diary and Validated Questionnaires in Women with Fecal Incontinence

INTRODUCTION AND HYPOTHESIS

Despite growing interest in a mobile-app bowel diary to assess fecal incontinence (FI) symptoms, data are limited regarding the correlation between mobile-app diary and questionnaire-based outcomes. The primary aim is to determine whether percentage reduction in FI episodes (FIEs)/week recorded on a mobile-app diary correlates with changes in scores of validated FI-symptom measures from baseline to 12 weeks in women with FI undergoing percutaneous tibial nerve stimulation (PTNS) versus sham.

METHODS

This is a planned secondary analysis of a multicenter randomized trial in which women with FI underwent PTNS or sham. FIEs were collected using a mobile-app diary at baseline and after 12 weekly sessions. FI-symptom-validated measures included St. Mark's, Accidental Bowel Leakage Evaluation, FI Severity Index (FISI), Colorectal Anal Distress Inventory, Colorectal Anal Impact Questionnaire, FI Quality of Life, Patient Global Impression of Improvement (PGI-I), and Patient Global Symptom Control (PGSC) rating. Spearman's correlation coefficient (ρ) was computed between %-reduction in FIEs/week and change in questionnaire scores from baseline to 12 weeks. Significance was set at 0.005 to account for multiple comparisons.

RESULTS

Baseline characteristics of 163 women (109 PTNS, 54 sham) include mean age 63.4±11.6, 81% white, body mass index 29.4±6.6 kg/m2, 4% previous FI surgeries, 6.6±5.5 FIEs/week, and St. Mark's score 17.4±2.6. A significant correlation was demonstrated between %-reduction in FIEs/week and all questionnaires (p<0.005). A moderate-strength correlation (|ρ|>0.4) was observed for St. Mark's (ρ=0.48), FISI (ρ=0.46), PGI-I (ρ=0.51), and PGSC (ρ=-0.43).

CONCLUSIONS

In women with FI randomized to PTNS versus sham, a moderate correlation was noted between FIEs measured via mobile-app diary and FI-symptom-validated questionnaire scores.

Characteristics associated with subjective and objective measures of treatment success in women undergoing percutaneous tibial nerve stimulation vs sham for accidental bowel leakage

INTRODUCTION AND HYPOTHESIS

In randomized trials both percutaneous tibial nerve stimulation (PTNS) and sham result in clinically significant improvements in accidental bowel leakage (ABL). We aimed to identify subgroups who may preferentially benefit from PTNS in women enrolled in a multicenter randomized trial.

METHODS

This planned secondary analysis explored factors associated with success for PTNS vs sham using various definitions: treatment responder using three cutoff points for St. Mark's score (≥3-, ≥4-, and ≥5-point reduction); Patient Global Impression of Improvement (PGI-I) of ≥ much better; and ≥50% reduction in fecal incontinence episodes (FIEs). Backward logistic regression models were generated using elements with significance of p<0.2 for each definition and interaction terms assessed differential effects of PTNS vs sham.

RESULTS

Of 166 women randomized, 160 provided data for at least one success definition. Overall, success rates were 65% (102 out of 158), 57% (90 out of 158), and 46% (73 out of 158) for ≥3-, ≥4-, and ≥5-point St Mark's reduction respectively; 43% (68 out of 157) for PGI-I; and 48% (70 out of 145) for ≥50% FIEs. Of those providing data for all definitions of success, 77% (109 out of 142) met one success criterion, 43% (61 out of 142) two, and 29% (41 out of 142) all three success criteria. No reliable or consistent factors were associated with improved outcomes with PTNS over sham regardless of definition.

CONCLUSIONS

Despite exploring diverse success outcomes, no subgroups of women with ABL differentially responded to PTNS over sham. Success results varied widely across subjective and objective definitions. Further investigation of ABL treatment success definitions that consistently and accurately capture patient symptom burden and improvement are needed.

Symptoms of anal incontinence and quality of life: a psychometric study of the Norwegian version of the ICIQ-B amongst hospital outpatients

BACKGROUND

The International Consultation on Incontinence Questionnaire-Bowel (ICIQ-B), a self-report, condition-specific questionnaire designed to assess symptoms of anal incontinence (AI), measures AI's impact on quality of life (QoL) along with perceived bowel patterns and bowel control amongst individuals with AI. In our study, we aimed to translate the ICIQ-B to Norwegian and investigate the Norwegian version's psychometric properties.

METHODS

To establish a relevant, comprehensive, and understandable Norwegian ICIQ-B, cognitive interviews were conducted with 10 patients with AI, and six clinical experts reviewed the translated scale. The Norwegian ICIQ-B's structural validity, scale reliability, and content validity were tested amongst patients with AI attending hospital outpatient clinics in three regions of Norway (N = 208).

RESULTS

Assessing the Norwegian ICIQ-B's content validity revealed that the questionnaire was relevant, comprehensive, and understandable. Missing data were infrequent (3.3%), and no floor or ceiling effects emerged. Three-factor and two-factor solution models, both with advantages and disadvantages, were found. The three-factor model offered the most parsimonious solution by covering most of the original scale, albeit with an unacceptably low reliability (α = .37) for the construct of bowel pattern. The two-factor model showed good reliability in terms of internal consistency for the constructs of bowel control (α = .80) and impact on QoL (α = .85) but was less parsimonious due to dismissing seven of the original 17 items and excluding the bowel pattern construct. Test-retest reliability demonstrates good stability for the Norwegian version, with an intra-class correlation coefficient of .90-.95 and weighted kappa of .39-.87 for single items.

CONCLUSIONS

Although the Norwegian version of ICIQ-B demonstrates good stability and content validity, the original constructs of bowel pattern and bowel control had to be adapted, whereas the construct of impact on QoL remained unchanged. Further psychometric testing of the Norwegian ICIQ-B's factor structure is therefore recommended.

Fecal Incontinence: Pathogenesis, Diagnosis, and Updated Treatment Strategies

Fecal incontinence (FI) is defined as the involuntary loss or passage of solid or liquid stool in patients. FI is a common and debilitating condition in men and women. The incidence increases with age and also often goes unreported to health care providers. It is crucial that providers ask at-risk patients about possible symptoms. Evaluation and management is tailored to specific symptoms and characteristics of the incontinence. If conservative methods fail to improve symptoms, then other surgical options are considered, such as sacral nerve stimulation and anal sphincter augmentation. This review provides an update on current and future therapies.

Accidental Bowel Leakage/Fecal Incontinence: Evidence-Based Management

Fecal incontinence is a highly prevalent and debilitating condition that negatively impacts quality of life. The etiology is often multifactorial and treatment can be hindered by lack of understanding of its mechanisms and available treatment options. This article reviews the evidence-based update for the management of fecal incontinence.

Evaluation of mobile applications for patients with fecal incontinence using a modified APPLICATIONS scoring system

INTRODUCTION AND HYPOTHESIS

Mobile applications (apps) are becoming an increasingly popular means of obtaining medical information. The aim of our study was to identify and evaluate patient-centered fecal incontinence (FI) mobile apps using a modified APPLICATIONS scoring system.

METHODS

We conducted searches in the Apple App and Google Play stores to identify FI-related mobile apps using search terms reflecting both commonly accepted medical terms as well as colloquial terms used by our patients with FI. Apps that were in English, relevant to FI, patient-centered, and medically accurate were included. Each eligible app was then independently evaluated by the three authors using a modified 17-point APPLICATIONS scoring system.

RESULTS

We identified 2785 apps upon initial search using FI search terms. Fourteen apps met eligibility criteria for scoring. Most apps were bowel movement trackers (13/14, 93%), of which only three allowed for tracking of FI episodes. Only one (7%) app contained educational information specific to FI. Ten (71%) apps were fully functional at no cost. Thirteen (93%) apps cited literature. Median APPLICATIONS score was 10 (IQR 9-11). "BristolStoolChart," "FreeToBe," and "PoopLog" each received the highest total score of 13.

CONCLUSIONS

Patient-centered mobile apps that provide FI-specific educational information or allow for FI symptom tracking are scarce. While we did discover some accurate sources of information and means of tracking bowel habits, patients are likely to encounter inaccurate or irrelevant information even when searching for FI-related apps using appropriate terminology. Future app development should include FI-specific symptom tracking and educational information from reputable sources.

The responsiveness and minimally important difference for the Accidental Bowel Leakage Evaluation questionnaire

INTRODUCTION AND HYPOTHESIS

We describe the responsiveness and minimally important difference (MID) of the Accidental Bowel Leakage Evaluation (ABLE) questionnaire.

METHODS

Women with bowel leakage completed ABLE, Patient Global Impression of Improvement, Colo-Rectal Anal Distress Inventory, and Vaizey questionnaires pretreatment and again at 24 weeks post-treatment. Change scores were correlated between questionnaires. Student's t tests compared ABLE change scores for improved versus not improved based on other measures. The MID was determined by anchor- and distribution-based approaches.

RESULTS

In 266 women, the mean age was 63.75 (SD = 11.14) and 79% were white. Mean baseline ABLE scores were 2.32 ± 0.56 (possible range 1-5) with a reduction of 0.62 (SD = 0.79) by 24 weeks. ABLE change scores correlated with related measures change scores (r = 0.24 to 0.53) and differed between women who improved and did not improve (all p < 0.001). Standardized response means for participants who improved were large ranging from -0.89 to -1.12. Distribution-based methods suggest a MID of -0.19 based on the criterion of one SEM and -0.28 based on half a standard deviation. Anchor-based MIDs ranged from -0.10 to -0.45. We recommend a MID of -0.20.

CONCLUSIONS

The ABLE questionnaire is responsive to change, with a suggested MID of -0.20.

Effect of oestrogen therapy on faecal incontinence in postmenopausal women: a systematic review

INTRODUCTION AND HYPOTHESIS

Faecal incontinence (FI) is prevalent in postmenopausal women. Oestrogen receptors have been identified in the anal sphincter and have been implicated in the pathogenesis and potential treatment. We sought to evaluate the literature regarding the impact of local and systemic oestrogen therapy on FI in postmenopausal women.

METHODS

A systematic review of all studies in postmenopausal women was performed to establish how oestrogen therapy affects FI. Eight articles were deemed eligible for inclusion following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Their quality was assessed using the Cochrane risk-of-bias tool (RoB-2) and Newcastle-Ottawa quality assessment scale.

RESULTS

One randomised controlled trial (RCT), two cohort studies, one observational and four cross-sectional studies were identified. The RCT showed an improvement in FI with anal oestrogen (p = 0.002), but this improvement was also observed in the placebo arm (p = 0.013) and no difference was seen between these groups. A prospective observational study demonstrated significant improvement with an oestrogen patch (p = 0.004), but had no control group. Conversely, a large prospective cohort study demonstrated an increased hazard ratio of FI with current (1.32; 95% CI, 1.20-1.45) and previous oestrogen use (1.26; 95% CI, 1.18-1.34) compared with non-users.

CONCLUSION

All studies had a high risk of bias and had conflicting views on the effects of oestrogen on FI in postmenopausal women. This review has identified the need for further research in this area by highlighting the paucity of good research for evidence-based practice. We believe that a further RCT of local oestrogen is mandated to draw a valid conclusion.

Effect of darifenacin on fecal incontinence in women with double incontinence

INTRODUCTION AND HYPOTHESIS

To evaluate change in fecal incontinence symptom severity after 8 weeks of darifenacin therapy in patients with double incontinence-urgency urinary incontinence (UUI) and fecal incontinence. Important secondary outcomes included fecal incontinence symptom distress and impact on quality of life, fecal incontinence episodes, global impression of improvement and overactive bladder symptom distress and impact.

METHODS

Prospective open-label cohort study of women presenting primarily with UUI, diagnosed with double incontinence and electing antimuscarinic therapy for UUI. Women ≥ 18 years with moderate or greater bothersome UUI and fecal incontinence of liquid/solid stool with St. Marks (Vaizey) score ≥ 12 were included. Subjects were treated with darifenacin 15 mg daily for 8 weeks. The primary outcome was change in fecal incontinence symptom severity using the St. Marks (Vaizey) score after 8 weeks. Sample size was based on the minimally important difference of the St. Marks, -5, and standard deviation, ± 8.5; 30 subjects provided 80% power and type I error of 0.05, including a 15% attrition rate.

RESULTS

Thirty-two women were consented with mean baseline St. Marks (Vaizey) score of 18.0 ± 3.0. Mean age was 66.5 ± 10.3 years. Twenty-eight subjects (29/32, 87.5%) completed assessments. St. Marks (Vaizey) score significantly improved from 18.0 to 11.0 [mean difference - 7.0, 95% confidence interval (CI): -8.7, -5.3], and 19 subjects (19/32,67.9%) met the minimally important difference. Statistically significant improvements were also noted in fecal incontinence frequency, quality of life, and overactive bladder symptom bother and quality of life (all p < 0.01).

CONCLUSIONS

Darifenacin can be considered a highly effective early intervention in women suffering from double incontinence.

CLINICAL TRIAL REGISTRATION

Bladder Antimuscarinic Medication and Accidental Bowel Leakage (BAMA), https://clinicaltrials.gov/ct2/show/NCT03543566 , NCT03543566.

Use of X-ray to Assess Fecal Loading in Patients with Gastrointestinal Symptoms

BACKGROUND/AIMS

There is currently no gold standard for evaluating stool burden in the colon for patients with gastrointestinal symptoms. We aim to examine the relationship between fecal loading on single view abdominal X-ray imaging and gastrointestinal symptoms such as constipation, diarrhea, bloating, and accidental bowel leakage in adult outpatients.

METHODS

This retrospective, cross-sectional study examined patients seen at University of Michigan from 2005 to 2017. Chart review of demographic information, reported gastrointestinal symptoms, past medical history, and abdominal radiographic imaging was performed. Bivariate analysis was performed to assess associations between these characteristics and fecal loading. Factors independently associated with fecal loading were identified using logistic regression. Significance was established at p < 0.05.

RESULTS

In total, 319 patients who had an X-ray were included in the final analysis, with 84.0% demonstrating fecal loading on the initial X-ray and most reporting constipation as a symptom (n = 214, 84.3%, p = 0.0334). In logistic regression, a chief complaint of constipation had higher odds of being associated with fecal loading on X-ray compared to diarrhea (adjusted OR 6.41; CI 1.51-27.24, p = 0.0118). Bloating as a reported symptom was statistically significant with an adjusted OR of 2.56 (CI 1.10-5.96, p = 0.0286).

CONCLUSIONS

Constipation (as a chief complaint) and bloating (as a symptom) were associated with fecal loading on X-ray imaging, while accidental bowel leakage and diarrhea were not.

Subtypes and symptoms of fecal incontinence in the Dutch population: a cross-sectional study

PURPOSE

To study the distribution of subtypes and symptoms of fecal incontinence in the general Dutch population.

METHODS

We performed a cross-sectional study in a representative sample of the general Dutch population. All respondents (N = 1259) completed the Groningen Defecation and Fecal Continence questionnaire. We assigned the respondents to a so-called healthy subgroup (n = 1008) and a comorbidity subgroup (n = 251). The latter subgroup comprised the respondents who reportedly suffered from chronic diseases and who had undergone surgery known to influence fecal continence. We defined fecal incontinence according to the Rome IV criteria.

RESULTS

The combination of urge fecal incontinence and soiling was the most frequent form of fecal incontinence in the total study group, the "healthy" subgroup, and the comorbidity subgroup (49.0, 47.3, and 51.5%). Passive fecal incontinence was the least frequent form of fecal incontinence in all three groups (4.0, 5.4, and 2.2%). The prevalence and severity of fecal incontinence was significantly higher in the comorbidity subgroup than in the "healthy" subgroup. Only in the comorbidity subgroup did the fecally incontinent respondents feel urge sensation significantly less often before defecating than their fecally continent counterparts (16.5 versus 48.8%, P < 0.001).

CONCLUSION

Urge fecal incontinence combined with soiling is commonest in the general Dutch population. Chronic diseases and bowel and pelvic surgery both increase and aggravate fecal incontinence.

Validation of an instrument to assess barriers to care-seeking for accidental bowel leakage in women: the BCABL questionnaire

INTRODUCTION AND HYPOTHESIS

Fewer than 30% of women with accidental bowel leakage (ABL) seek care, despite the existence of effective, minimally invasive therapies. We developed and validated a condition-specific instrument to assess barriers to care-seeking for ABL in women.

METHODS

Adult women with ABL completed an electronic survey about condition severity, patient activation, previous care-seeking, and demographics. The Barriers to Care-seeking for Accidental Bowel Leakage (BCABL) instrument contained 42 potential items completed at baseline and again 2 weeks later. Paired t tests evaluated test-retest reliability. Factor analysis evaluated factor structure and guided item retention. Cronbach's alpha evaluated internal consistency. Within and across factor item means generated a summary BCABL score used to evaluate scale validity with six external criterion measures.

RESULTS

Among 1,677 click-throughs, 736 (44%) entered the survey; 95% of eligible female respondents (427 out of 458) provided complete data. Fifty-three percent of respondents had previously sought care for their ABL; median age was 62 years (range 27-89); mean Vaizey score was 12.8 (SD = 5.0), indicating moderate to severe ABL. Test-retest reliability was excellent for all items. Factor extraction via oblique rotation resulted in the final structure of 16 items in six domains, within which internal consistency was high. All six external criterion measures correlated significantly with BCABL score.

CONCLUSIONS

The BCABL questionnaire, with 16 items mapping to six domains, has excellent criterion validity and test-retest reliability when administered electronically in women with ABL. The BCABL can be used to identify care-seeking barriers for ABL in different populations, inform targeted interventions, and measure their effectiveness.

Barriers to seeking care for accidental bowel leakage: a qualitative study

INTRODUCTION AND HYPOTHESIS

Fewer than 50 % of women with urinary incontinence (UI) and 30 % of women with accidental bowel leakage (ABL) seek care. We sought to describe barriers to care seeking for ABL to inform development of an instrument to measure these barriers.

METHODS

We recruited women with ABL with varied prior care-seeking experiences to participate in focus groups and cognitive interviews so we could understand factors that may have prevented or delayed care seeking. Focus groups continued until thematic saturation was reached using conventional content analysis. Final themes were established and characterized by comparing within and across the focus groups and with previously described UI and ABL care-seeking barriers. Cognitive interviews were confirmatory.

RESULTS

Thirty-nine women (aged 46-85) participated in six focus groups and ten cognitive interviews; 89 % were white, 8 % African American, and 3 % Latina. We identified 12 barriers to seeking care for ABL: (1) Lack of knowledge about the condition; (2) Lack of knowledge about treatment; (3) Fear of testing/treatment; (4) Normative thinking; (5) Avoidance/denial; (6) Life impact; (7) Embarrassment/shame; (8) Self-blame; (9) Stigma; (10) Isolation; (11) Provider barriers; (12) Access limitations. These 12 barriers encompassed three overarching themes: the internalized self in relation to ABL; perceptions about ABL and its treatments; and interaction with the healthcare system.

CONCLUSIONS

ABL care-seeking barriers are similar to those described for UI, with the notable addition of lack of knowledge that ABL is a medical condition experienced by others. Interventions to promote access to effective treatments for ABL should include information about prevalence and treatability.

Evidence-Based Update on Treatments of Fecal Incontinence in Women

Fecal incontinence is a highly prevalent and distressing condition that has a negative impact on quality of life. The etiology is often multifactorial, and the evaluation and treatment of this condition can be hindered by a lack of understanding of the mechanisms and currently available treatment options. This article reviews the evidence-based update for the management of fecal incontinence.

Fecal Incontinence and Pelvic Floor Dysfunction in Women: A Review

Pelvic floor dysfunction and fecal incontinence is a common and debilitating condition in women, particularly as women age, and often goes under-reported to health care providers. It is important for providers to ask patients about possible symptoms. An algorithm for evaluation and treatment is presented. Current and future therapies are described and discussed.

An Evidence-Based Approach to the Evaluation, Diagnostic Assessment and Treatment of Fecal Incontinence in Women

Fecal incontinence (FI) is a debilitating disorder which negatively impacts quality of life. The etiology is often multifactorial and although most women with FI are able to be treated, many remain untreated because a significant proportion of women do not report their symptoms and seek care. The evaluation and treatment of FI can be also hindered by a lack of understanding of the mechanisms and current options. This article provides a review on the evidence-based evaluation and management for FI.