Successful outcome following a multimodal pelvic rehabilitation program in a woman with neurogenic bladder and bowel dysfunction: A case report

BACKGROUND

Neurogenic bladder and bowel dysfunctions lead to physical, social, and emotional disability and affects one's quality of life. Initial treatment is conservative including several rehabilitation techniques such as pelvic floor muscle training, biofeedback, electrical stimulation, and posterior tibial nerve stimulation.

OBJECTIVE

In this case report, a 45-year-old woman with neurogenic bladder and bowel dysfunction was presented.

CASE DESCRIPTION

Her urinary and fecal incontinence symptoms began twenty years before this episode of care, after an incomplete spinal cord injury secondary to spinal ependymoma and syringomyelia. She discontinued medical treatments due to side effects and ceased intermittent catheterization. A multimodal pelvic rehabilitation program was administered consisting of posterior tibial nerve stimulation, active pelvic floor muscle training accompanied by biofeedback, and electrical stimulation of pelvic floor muscles.

OUTCOMES

There were clinically important favorable differences in the scores of King's health questionnaire (reductions in symptom severity from 25 to 18 and in each of the impact of incontinence, physical and social limitations, personal relationships, sleep/energy, and severity measures from 100 to 67), pelvic floor distress inventory (decreased from 257 to 146) and female sexual function index (increased from 15.1 to 25.1) after 12 weeks of a multimodal pelvic rehabilitation program. Manual muscle tests demonstrated improvements in pelvic floor muscle strength and endurance.

CONCLUSION

A 12-week multimodal pelvic rehabilitation program reduced urinary and fecal incontinence symptoms, together with improvements in her sexual life and alleviation of neuropathic pain.

Vaginal delivery in women with perianal Crohn's disease: why not?

BACKGROUND

Pregnant women with active perianal Crohn's disease indicate a cesarean delivery according to the current European Crohn's and Colitis Organisation guidelines. This advice is based on the assumption that vaginal delivery leads to exacerbation of perianal disease and worsening of fecal continence. However, there is no strong evidence to support this.

OBJECTIVE

This study aims to examine the effects of the delivery method on perianal disease progression and fecal incontinence in women with perianal Crohn's disease.

STUDY DESIGN

In this retrospective cohort study, 102 women were selected from the 1000 inflammatory bowel disease cohort of a tertiary hospital in the Netherlands. All women are aged >18 years, have perianal Crohn's disease, and have given birth. In addition, all women completed a questionnaire. Fecal continence was scored using the Vaizey score. Using SPSS, descriptive analysis and linear regression analysis were performed, and P values <.05 were considered statistically significant.

RESULTS

The cesarean delivery rate within our cohort was 19.5%. Within the group of women who delivered at least one child vaginally (n=84), 25.5% reported alteration of fecal continence, compared with 13.1% in women who only had cesarean delivery (n=18). After a mean follow-up of 15 years, the median Vaizey score within the cesarean delivery group was 5, compared with 7 in the vaginal delivery group. Within the vaginal delivery group, 18.8% reported perianal disease progression, compared with 22.2% in the cesarean delivery group. No significant relation between mode of delivery and fecal continence or perianal disease progression was found (B, 0,97 [-1,19 to 3,14], P=.38).

CONCLUSION

Fecal incontinence and perianal disease progression after vaginal delivery in Crohn's disease women with active perianal fistula is not significantly increased in this retrospective cohort. This study opens the discussion for more tailored obstetric advice in women with perianal Crohn's disease.

A comparison of function lumen imaging probe measurements of anal sphincter function in fecal incontinence

BACKGROUND

The functional lumen imaging probe (FLIP) is a test of anal sphincter distensibility under evaluation by specialist centers. Two measurement protocols termed "stepwise" and "ramp" are used, risking a lack of standardization. This study aims to compare the performance of these protocols to establish if there are differences between them.

METHODS

Patients with fecal incontinence were recruited and underwent measurement with both protocols at a tertiary pelvic floor referral unit. Differences in minimum diameter, FLIP bag pressure, and distensibility index (DI) at rest and during squeeze were calculated at various FLIP bag volumes.

KEY RESULTS

Twenty patients (19 female, mean age 61 [range: 38-78]) were included. The resting minimum diameter at 30 and 40 mL bag volumes were less in the stepwise protocol (mean bias: -0.55 mm and -1.18 mm, p < 0.05) along with the DI at the same bag volumes (mean bias: -0.37 mm2/mmHg and -0.55 mm2/mmHg, p < 0.05). There was also a trend towards greater bag pressures at 30 mL (mean bias: +2.08 mmHg, p = 0.114) and 40 mL (mean bias: +2.81 mmHg, p = 0.129) volumes in the stepwise protocol. There were no differences between protocols in measurements of minimum diameter, maximum bag pressure, or DI during voluntary squeeze (p > 0.05).

CONCLUSION AND INFERENCES

There are differences between the two commonly described FLIP measurement protocols at rest, although there are no differences in the assessment of squeeze function. Consensus agreement is required to agree the most appropriate FLIP measurement protocol in assessing anal sphincter function.

The association between vitamin-D deficiency and fecal incontinence

BACKGROUND

Vitamin-D is essential for musculoskeletal health. We aimed to determine whether patients with fecal incontinence (FI): (1) are more likely to have vitamin-D deficiency and, (2) have higher rates of comorbid medical conditions.

METHODS

We examined 18- to 90-year-old subjects who had 25-hydroxy vitamin-D levels, and no vitamin-D supplementation within 3 months of testing, in a large, single-institutional electronic health records dataset, between 2017 and 2022. Cox proportional hazards survival analysis was used to assess association of vitamin-D deficiency on FI.

KEY RESULTS

Of 100,111 unique individuals tested for serum 25-hydroxy vitamin-D, 1205 (1.2%) had an established diagnosis of FI. Most patients with FI were female (75.9% vs. 68.7%, p = 0.0255), Caucasian (66.3% vs. 52%, p = 0.0001), and older (64.2 vs. 53.8, p < 0.0001). Smoking (6.56% vs. 2.64%, p = 0.0001) and GI comorbidities, including constipation (44.9% vs. 9.17%, p = 0.0001), irritable bowel syndrome (20.91% vs. 3.72%, p = 0.0001), and diarrhea (28.55% vs. 5.2%, p = 0.0001) were more common among FI patients. Charlson Comorbidity Index score was significantly higher in patients with FI (5.5 vs. 2.7, p < 0.0001). Significantly higher proportions of patients with FI had vitamin-D deficiency (7.14% vs. 4.45%, p < 0.0001). Moreover, after propensity-score matching, rate of new FI diagnosis was higher in patients with vitamin-D deficiency; HR 1.9 (95% CI [1.14-3.15]), p = 0.0131.

CONCLUSION & INFERENCES

Patients with FI had higher rates of vitamin-D deficiency along with increased overall morbidity. Future research is needed to determine whether increased rate of FI in patients with vitamin-D deficiency is related to frailty associated with increased medical morbidities.

Knowledge of nursing staff before and after training on incontinence-associated dermatitis

OBJECTIVE

To verify the knowledge of nursing staff before and after training on incontinence-associated dermatitis.

METHOD

A study before and after an educational intervention carried out with nursing staff from the medical and surgical clinics and intensive care unit of the university hospital in June 2023. The training took place over three meetings. Data was collected using a questionnaire administered immediately before and after the training. McNemar's test for dependent samples was used to compare before and after training.

RESULTS

25 nurses and 14 nursing technicians took part. The items that showed statistical significance were related to the identification and correct differentiation of dermatitis associated with incontinence and pressure injury; and the correct way to sanitize the skin.

CONCLUSION

The training of the nursing team made it possible to assess their knowledge of how to identify, prevent and treat incontinence-associated dermatitis.

Sacral Neuromodulation in Patients With Low Anterior Resection Syndrome: The SANLARS Randomized Clinical Trial

BACKGROUND

Sacral neuromodulation might be effective to palliate low anterior resection syndrome after rectal cancer surgery, but robust evidence is not available.

OBJECTIVE

To assess the impact of sacral neuromodulation on low anterior resection syndrome symptoms as measured by validated scores and bowel diaries.

DESIGN

Randomized, double-blind, 2-phased, controlled, multicenter crossover trial (NCT02517853).

SETTINGS

Three tertiary hospitals.

PATIENTS

Patients with major low anterior resection syndrome 12 months after transit reconstruction after rectal resection who had failed conservative treatment.

INTERVENTIONS

Patients underwent an advanced test phase by stimulation for 3 weeks and received the pulse generator implant if a 50% reduction in low anterior resection syndrome score was achieved. These patients entered the randomized phase in which the generator was left active or inactive for 4 weeks. After a 2-week washout, the sequence was changed. After the crossover, all generators were left activated.

MAIN OUTCOME MEASURES

The primary outcome was low anterior resection syndrome score reduction. Secondary outcomes included continence and bowel symptoms.

RESULTS

After testing, 35 of 46 patients (78%) had a 50% or greater reduction in low anterior resection syndrome score. During the crossover phase, all patients showed a reduction in scores and improved symptoms, with better performance if the generator was active. At 6- and 12-month follow-up, the mean reduction in low anterior resection syndrome score was -6.2 (95% CI -8.97 to -3.43; p < 0.001) and -6.97 (95% CI -9.74 to -4.2; p < 0.001), with St. Mark's continence score -7.57 (95% CI -9.19 to -5.95, p < 0.001) and -8.29 (95% CI -9.91 to -6.66; p < 0.001). Urgency, bowel emptiness sensation, and clustering episodes decreased in association with quality-of-life improvement at 6- and 12-month follow-up.

LIMITATIONS

The decrease in low anterior resection syndrome score with neuromodulation was underestimated because of an unspecific measuring instrument. There was a possible carryover effect in sham stimulation sequence.

CONCLUSIONS

Neuromodulation provides symptoms and quality-of-life amelioration, supporting its use in low anterior resection syndrome. See Video Abstract .

NEUROMODULACIN SACRA EN PACIENTES CON SNDROME DE RESECCIN ANTERIOR BAJA ENSAYO CLNICO ALEATORIZADO SANLARS

ANTECEDENTES:La neuromodulación sacra podría ser eficaz para paliar el síndrome de resección anterior baja después de la cirugía de cáncer de recto, pero no hay pruebas sólidas disponibles.OBJETIVO:Evaluar el impacto de la neuromodulación sacra en los síntomas del síndrome de resección anterior baja, medido mediante puntuaciones validadas y diarios intestinales.DISEÑO:Ensayo cruzado multicéntrico, controlado, aleatorizado, doble ciego, de dos fases (NCT02517853).LUGARES:Tres hospitales terciarios.PACIENTES:Pacientes con puntuación de resección anterior baja importante, 12 meses después de la reconstrucción del tránsito después de la resección rectal en quienes había fracasado el tratamiento conservador.INTERVENCIONES:Los pacientes se sometieron a una fase de prueba avanzada mediante estimulación durante tres semanas y se les implantó el generador de impulsos si se lograba una reducción del 50% en la puntuación del síndrome de resección anterior baja, ingresando a la fase aleatorizada en la que el generador se dejaba activo o inactivo durante cuatro semanas. Después de observar por 2 semanas, se cambió la secuencia. Después del cruce, todos los generadores quedaron activados.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue la reducción de la puntuación del síndrome de resección anterior baja. Los resultados secundarios incluyeron continencia y síntomas intestinales.RESULTADOS:Después de las pruebas, 35 de 46 pacientes (78%) tuvieron una reducción ≥50% en la puntuación del síndrome de resección anterior baja. Durante el cruce, todos los pacientes mostraron una reducción en las puntuaciones y una mejora de los síntomas, con un mejor rendimiento si el generador estaba activo. A los 6 y 12 meses de seguimiento, la reducción media en la puntuación del síndrome de resección anterior baja fue -6,2 (-8,97; -3,43; p < 0,001) y -6,97 (-9,74; -4,2; p < 0,001), con Puntuación de continencia de St. Mark's -7,57 (-9,19; -5,95, p < 0,001) y -8,29 (-9,91; -6,66; p < 0,001). La urgencia, la sensación de vacío intestinal y los episodios de agrupamiento disminuyeron en asociación con una mejora en la calidad de vida a los 6 y 12 meses de seguimiento.LIMITACIONES:La disminución en la puntuación del síndrome de resección anterior baja con neuromodulación se subestimó debido a un instrumento de medición no específico. Posible efecto de arrastre en la secuencia de estimulación simulada.CONCLUSIONES:La neuromodulación mejora los síntomas y la calidad de vida, lo que respalda su uso en el síndrome de resección anterior baja. (Traducción-Dr. Mauricio Santamaria ).

The Prevalence of Incontinence and Its Association With Urinary Tract Infections, Dermatitis, Slips and Falls, and Behavioral Disturbances Among Older Adults in Medicare Fee-for-Service

PURPOSE

The purpose of this study was to examine the prevalence of urinary (UI), fecal (FI), and dual incontinence (DI) in older adults and their association with urinary tract infections, dermatitis, slips and falls, and behavioral disturbances based on Medicare fee-for-service (FFS) claims data.

DESIGN

Retrospective analysis.

SUBJECTS AND SETTINGS

Data from administrative claims from the CMS Medicare Limited Data Set (5% sample) for all months in 2018 were reviewed. The analysis was limited to FFS Medicare beneficiaries, with minimum of 3-month enrollment in Parts A and B who were at least 65 years old. This cohort included 1.2 million beneficiaries in the United States.

METHODS

We used diagnosis codes to identify members with incontinence and grouped these members into 3 categories (UI only, FI only, and DI). We also divided claims based on 4 sites of care (nursing home, skilled nursing facility, home health, and self- or family care). We then determined the prevalence of (1) urinary tract infections (UTIs), (2) dermatitis, (3) slips and falls, and (4) behavioral disturbances for each type of incontinence.

RESULTS

We found that 11.2% of Medicare members had a claims-based diagnosis of incontinence in 2018. On average, those diagnosed with incontinence experienced 5 times more UTIs, 2 times as many dermatitis events, more than twice as many slips and falls, and 2.8 times more behavior disturbances compared to those without an incontinence diagnosis. For those with DI, the prevalence of the 4 outcomes was significantly higher (between 22% and 185%) compared to those with UI only.

CONCLUSIONS

Findings show that Medicare beneficiaries diagnosed as incontinent experience a much higher prevalence of UTIs, dermatitis, slips and falls, and behavioral disturbances compared to those without a diagnosis of incontinence. Our results suggest that incontinence may be an important indicator diagnosis for multiple other conditions and, if not well-managed, may challenge the desire for those who are incontinent to age at home.

Influence of pelvic floor disorders on sexuality in women

OBJECTIVE

To determine the association between different pelvic floor disorders and the presence of sexual dysfunction in women.

METHOD

An observational study of non-pregnant women was carried out in Spain in 2021 and 2022. To assess the presence of pelvic floor problems, the Pelvic Floor Distress Inventory (PFDI-20) was used, consisting of the subscales Pelvic Organ Prolapse Distress Inventory-6 (POPDI-6; prolapse symptoms), Colorectal-Anal Distress Inventory (CRADI-8; colorectal symptoms), and Urinary Distress Inventory-6 (UDI-6; urinary symptoms). The validated tool, Female Sexual Function (FSF), was used to evaluate female sexual function.

RESULTS

In total, 1008 women participated. Of these, 288 (28.6%) had some type of sexual dysfunction. Regarding symptoms, 52 (5.2%) stated that they do not reach orgasm and 172 (17.1%) said they had never or occasionally felt sexual desire in the last month. Women with sexual dysfunctions had higher mean scores on the POPDI-6, CRADI-8, and UDI-6 subscales than those who did not have sexual dysfunction (P ≤ 0.005). Risk factors identified included being postmenopausal, with an adjusted odds ratio (aOR) of 2.98 (95% confidence interval [CI] 2.12-4.18), and a greater impact of the symptoms of pelvic floor problems as assessed by the PFDI-20 scale, in such a way that for each point increase the probability of sexual dysfunction increases with an aOR of 1.008 (95% CI 1.005-1.011).

CONCLUSION

Women with pelvic floor disorders and postmenopausal women present sexual dysfunction more frequently.

The Severity of Fecal Problems Is Negatively Associated With Quality of Life in a Dutch Population Without Bowel Function Comorbidities

BACKGROUND

Constipation and fecal incontinence negatively influence quality of life. The association between the severity of fecal problems and quality of life has not been investigated in the general population without bowel function comorbidities.

OBJECTIVE

To investigate the association between the severity of constipation and fecal incontinence and quality of life in patients without comorbidities influencing bowel function.

DESIGN

A population-based, cross-sectional study.

SETTINGS

The study involved 3668 Dutch study participants.

PATIENTS

A survey company conducted a population-wide study of the general Dutch population. Altogether, 5000 Dutch citizens completed the Groningen Defecation and Fecal Continence and Short Form-36 questionnaires. The data on 3668 respondents without comorbidities that could influence bowel function were included for analysis (study group).

MAIN OUTCOME MEASURES

The severity of constipation (Agachan score) and fecal incontinence (Wexner score) in relation to the quality-of-life scores.

RESULTS

In the study group (n = 3668), 487 had constipation (13.3%), 116 had fecal incontinence (3.2%), and 64 had 2 coexisting fecal problems (1.7%). In the multivariable analysis, all quality-of-life domains were negatively associated with the severity of constipation and fecal incontinence. The associations between the severity of constipation and quality of life were stronger (highest: ß = -2.413; 95% CI, -2.681 to -2.145; p < 0.001) than those of fecal incontinence (highest: ß = -1.280; 95% CI, -1.681 to -.880; p < 0.001). We also found that a longer duration of bowel complaints coincided with higher severity scores, especially for constipation. Respondents mostly rated their defecation health as positive, regardless of the severity of their fecal problems.

LIMITATIONS

Cross-sectional design.

CONCLUSIONS

The severity of constipation and fecal incontinence is significantly associated with reduced quality of life, with the severity of constipation having stronger associations than fecal incontinence. Given respondents' unawareness of their fecal problems and the progressive character, timely intervention is advocated. See Video Abstract .

LA GRAVEDAD DE LOS PROBLEMAS FECALES SE ASOCIA NEGATIVAMENTE CON LA CALIDAD DE VIDA EN UNA POBLACIN HOLANDESA SIN COMORBILIDADES DE LA FUNCIN INTESTINAL

ANTECEDENTES:El estreñimiento y la incontinencia fecal influyen negativamente en la calidad de vida. La asociación entre la gravedad de los problemas fecales y la calidad de vida no se ha investigado en la población general sin comorbilidades de la función intestinal.OBJETIVO:Investigar la asociación entre la gravedad del estreñimiento y la incontinencia fecal y la calidad de vida en la población holandesa general sin comorbilidades que influyan en la función intestinal.DISEÑO:Estudio transversal de base poblacional.ENTORNO CLINICO:El estudio involucró a 3668 participantes holandeses.PACIENTES:Una empresa de encuestas realizó un estudio poblacional de la población holandesa en general. En total, 5.000 ciudadanos holandeses completaron los cuestionarios Groningen Defecation and Fecal Continence y Short-Form 36. Se incluyeron para el análisis los datos de 3668 encuestados sin comorbilidades que pudieran influir en la función intestinal (grupo de estudio).PRINCIPALES MEDIDAS DE RESULTADO:La gravedad del estreñimiento (puntuación de Agachan) y la incontinencia fecal (puntuación de Wexner) en relación con las puntuaciones de calidad de vida.RESULTADOS:En el grupo de estudio (n = 3668), 487 tenían estreñimiento (13,3%), 116 tenían incontinencia fecal (3,2%) y 64 tenían 2 problemas fecales coexistentes (1,7%). En el análisis multivariable, todos los dominios de calidad de vida se asociaron negativamente con la gravedad del estreñimiento y la incontinencia fecal. Las asociaciones entre la gravedad del estreñimiento y la calidad de vida fueron más fuertes (más alta: ß = -2,413; IC del 95 %, -2,681 a -2,145; p < 0,001) que las de la incontinencia fecal (más alta: ß = -1,280; 95 IC %: -1,681 a -0,880; p < 0,001). También encontramos que una mayor duración de las molestias intestinales coincidió con puntuaciones de gravedad más altas, especialmente para el estreñimiento. La mayoría de los encuestados calificaron su salud en la defecación como positiva, independientemente de la gravedad de sus problemas fecales.LIMITACIONES:Diseño transversal.CONCLUSIONES:La gravedad del estreñimiento y la incontinencia fecal se asocia significativamente con una calidad de vida reducida; la gravedad del estreñimiento tiene asociaciones más fuertes que la incontinencia fecal. Dado el desconocimiento de los encuestados sobre sus problemas fecales y el carácter progresivo, se recomienda una intervención oportuna. (Traducción- Dr. Francisco M. Abarca-Rendon ).

Comparison of etiological and physiological characteristics of fecal incontinence in men and women

Fecal incontinence (FI) is often underreported and underestimated in men. Our aims were to clarify the causes and the physiological characteristics of FI in men and to underline the differences between etiological and physiological factors in men and women diagnosed with FI. The study cohort encompassed 200 men and 200 women who underwent anatomical and physiological evaluation for FI in a tertiary referral center specializing in pelvic floor disorders. All patients underwent endoanal ultrasound and anorectal manometry. Evacuation proctography was performed in some patients. Demographic, medical, anatomical, and physiological parameters were compared between the two study groups. Urge incontinence was the most frequent type of FI in both genders. In men, anal fistula, history of anal surgeries, rectal tumors, and pelvic radiotherapy were common etiologic factors, whereas history of pelvic surgeries was more common in women. Associated urinary incontinence was reported more frequently by women. External anal sphincter defects, usually anterior, were more common in women (M: 1.5%, F: 24%, P < 0.0001), whereas internal anal sphincter defect prevalence was similar in men and women (M: 6%, F: 12%, P = 0.19). Decreased resting and squeeze pressures were less common in men (M: 29%, F: 46%, P < 0.0001: M: 44%, F: 66%, P < 0.0001). The incidence of rectal hyposensitivity was higher in men (M: 11.1%, F: 2.8%, P < 0.0001), whereas rectal hypersensitivity was higher in women (M: 5.8%, F: 10.8%, P < 0.0001). Anorectal dyssynergia was more common in men (M: 66%, F: 37%, P < 0.0001). Significantly different etiological factors and physiological characteristics for FI were found in men. Acknowledging these differences is significant and may yield better treatment options.NEW & NOTEWORTHY Fecal incontinence (FI) in men has different etiological factors when compared with women. The prevalence of internal anal sphincter defect among men with FI was similar to women. Different manometric measurements were found among men with FI: decreased anal pressures were less common among men, whereas rectal hyposensitivity and anorectal dyssynergia were more common among men.

Monitoring-Based Model for Personalizing Fecal Incontinence in Patients With Crohn's Disease: A Multicenter Inception Cohort Study

BACKGROUND AND AIMS

Fecal incontinence (FI) is a common complaint that greatly affects the quality of life of patients with Crohn's disease (CD) and is associated with the clinical characteristics of CD. We aimed to identify risk factors related to FI and construct a risk prediction model for FI in patients with CD.

METHODS

This retrospective study included 600 Chinese patients with CD from 4 IBD centers between June 2016 and October 2021. The patients were assigned to the training (n = 480) and testing cohorts (n = 120). Two nomograms were developed based on the logistic regression and Cox regression models to predict the risk factors for FI in patients with CD. The discriminatory ability and accuracy of the nomograms were evaluated using the receiver operating characteristic (ROC) curves and the area under the ROC curves (AUCs). Additionally, the Kaplan-Meier survival curve was also used further to validate the clinical efficacy of the Cox regression model.

RESULTS

The overall prevalence of FI was 22.3% (n = 134 of 600). In the logistic regression model, age at diagnosis (odds ratio [OR], 1.032; P = .033), penetrating behavior of disease (OR, 3.529; P = .008) and Perianal Disease Activity Index score >4 (OR, 3.068; P < .001) were independent risk factors for FI. In the Cox regression model, age at diagnosis (hazard ratio [HR], 1.027; P = .018), Montreal P classification (HR, 2.608; P = .011), and Perianal Disease Activity Index score >4 (HR, 2.190; P = .001) were independent predictors of the prevalence of FI over time. Two nomograms were developed to facilitate risk score calculation, and they showed good discrimination ability according to AUCs.

CONCLUSIONS

In this study, we identified 4 risk factors related to the prevalence of FI and developed 2 models to effectively predict the risk scores of FI in CD patients, helping to delay the course of FI and improve the prognosis with timely intervention.

Effects of Posterior Tibial Nerve Stimulation on Fecal Incontinence: An Umbrella Review

PURPOSE

This study aimed to summarize relevant data from previous systematic reviews (SRs) and conduct comprehensive research on the clinical effects of posterior tibial nerve stimulation (PTNS), via the transcutaneous posterior tibial nerve stimulation (TPTNS) or percutaneous posterior tibial nerve stimulation (PPTNS) method on fecal incontinence (FI).

MATERIALS AND METHODS

In adherence to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, a systematic search was conducted on PubMed, Embase, Scopus, and Web of Science databases. We included English-language, full-text SRs reporting outcomes for FI following either PPTNS or TPTNS. The quality of included studies was assessed using the Joanna Briggs Institute checklist. In addition, reanalyzing the meta-analyses was conducted using Comprehensive Meta-Analysis (CMA) software version 3.0 to achieve effect sizes and the level of statistical significance was set at p ≤ 0.05.

RESULTS

From a total of 835 citations, 14 SRs met our inclusion criteria. Four of these also conducted a meta-analysis. Most SRs reported an overall improvement in different study parameters, including bowel habits and quality of life. However, there were major inconsistencies across the results. The most studied outcome was FI episodes, followed by incontinence score. The summary outcomes showed no statistically significant changes in comparing PTNS with sham or sacral nerve stimulation (SNS) for FI (p > 0.05). However, the results of subgroup analysis based on the type of intervention in the control group revealed that FI episodes were significantly fewer than in the PTNS arm, whereas PTNS led to fewer episodes of FI than did the sham. In terms of incontinence score, the results showed that PTNS compared with sham did not change the incontinence score; however, SNS improved the score significantly in one eligible study for reanalysis when compared with PTNS (p < 0.001).

CONCLUSIONS

The findings of the current umbrella review suggest that PTNS can potentially benefit patients with FI. However, this is concluded from studies with a limited population, disregarding the etiology of FI and with limited follow-up duration. Therefore, caution must be taken in contemplating the results.

Accuracy of patient-reported bowel symptoms for fecal incontinence: Historical recall versus prospective evaluation

INTRODUCTION

Fecal incontinence (FI) is characterized by both irregular and unpredictable bowel symptoms. An accurate history of symptoms is important for diagnosis and guiding management. Whether a patient's history of bowel symptoms is reliable or if there is recall bias is unknown.

AIM

To evaluate the accuracy of FI symptoms based on patient's recall compared with a prospective stool diary.

METHODS

FI (Rome IV) patients completed a bowel questionnaire that included leakage episodes and stool consistency. Subsequently they completed a one-week FI stool diary. Agreement and correlation between historical recall and stool diary were compared.

RESULTS

One hundred patients participated. On average they reported 12 bowel movements (BMs) and five FI episodes per week. Fifty-two percent had completed under-graduation, 33% high school and 15% postgraduation. Using recall, 23% of patients accurately reported the number of FI episodes, whereas 41% underestimated and 36% overestimated its prevalence compared to the FI diary. Similarly, the concordance for the number of BMs was 30%, urgency was 54%, amount of stool leakage was 16%, and stool consistency was 12.5%. The concordance for nocturnal FI events, use of pads and lack of stool awareness were 63%, 75%, and 66.6% respectively.

CONCLUSION

There is poor concordance for key bowel symptoms including the number of FI episodes as reported by FI patients, suggesting significant recall bias. Thus, historical recall of chronic FI symptoms may be less accurate. A prospective stool diary could provide more accurate information for the evaluation of FI patients.

Long-Term Outcome of Transcutaneous Posterior Tibial Nerve Stimulation in the Treatment of Functional Non-Retentive Fecal Incontinence in Children

BACKGROUND

Functional non-retentive fecal incontinence (FNRFI) is a psychologically upsetting and embarrassing issue and affects children's quality of life negatively.

AIM OF THIS STUDY

Evaluation of the short and long-term effect of Bilateral transcutaneous posterior tibial nerve stimulation (BTPTNS) in the treatment of FNRFI in children and its impact on the quality of life (QoL). Methodology: The current randomized controlled study included 94 Children with FNRFI who were randomly allocated into two equal groups. Group A received BTPTNS and Group B Received Sham BTPTNS. Follow-up was planned for 24 months for manometric findings, incontinence score, Incontinence episodes, and the QoL.

RESULTS

The incontinence score was significantly decreases in Group A more than what was reported in Group B at 6, 12, 24 months follow up . In group A 53.2% of the included children who received BTPTNS showed a decrease in the incontinence episodes more than 75% and among them, 23.4% were fully continent. All the QoL domains were significantly improved in Group A after 6, 12, and 24 months when compared with Group B.

CONCLUSION

BTPTNS can be a good modality in the treatment of FNRFI with favorable long-term maintenance of its effect together with a remarkable positive impact on all domains of QoL.

Faecal incontinence-a comprehensive review

Introduction

Faecal incontinence (FI) is a distressing and often stigmatizing condition characterised as the recurrent involuntary passage of liquid or solid faeces. The reported prevalence of FI exhibits considerable variation, ranging from 7 to 15% in the general population, with higher rates reported among older adults and women. This review explores the pathophysiology mechanisms, the diagnostic modalities and the efficiency of treatment options up to date.

Methods

A review of the literature was conducted to identify the pathophysiological pathways, investigation and treatment modalities.

Result and discussion

This review provides an in-depth exploration of the intricate physiological processes that maintain continence in humans. It then guides the reader through a detailed examination of diagnostic procedures and a thorough analysis of the available treatment choices, including their associated success rates. This review is an ideal resource for individuals with a general medical background and colorectal surgeons who lack specialized knowledge in pelvic floor disorders, as it offers a comprehensive understanding of the mechanisms, diagnosis, and treatment of faecal incontinence (FI).

Evaluation of the effect of biofeedback in women with urinary and fecal incontinence referring to the hospitals of Islamic Azad university of medical sciences, Tehran branch, Iran (2021)

Background and Purpose

Urinary incontinence (URIN) and fecal incontinence (FEIN) are common in women, which affect various aspects of their daily life and general health. Therefore, the main purpose of this study was to evaluate the effect of biofeedback (BFB) in women with urinary and FEIN referring to the hospitals of Islamic Azad University of Medical Sciences, Tehran branch, Iran (2021).

Materials and Methods

This research was a cohort study that was conducted on 100 women with urinary and FEIN who were referred to selected hospitals of the Islamic Azad University of Medical Sciences, Tehran branch. In this study, before and after BFB, the amount of urinary and FEIN in patients was measured and finally compared by SPSS-ver. 16 software.

Results

The results of this study showed that the frequency of patients with URIN and FEIN was equal to 66 (66%) and 34 (66%) patients, respectively. After treatment with BFB, 39 (59.1%) patients with URIN and 39 (59.1%) patients with FEIN had symptom improvement. The mean body mass index and the number of pregnancies in patients who improved urinary and FEIN symptoms after BFB were significantly lower than in patients who did not improve symptoms.

Conclusion

Based on the findings of the present study, it can be concluded that effective and significant factors on the improvement of urinary and FEIN symptoms after BFB include fiber consumption, the presence of underlying diseases such as diabetes, blood pressure, type of delivery, history of depression, history of anorectal surgery, and vaginal delivery was difficult. In addition, based on the findings of the study, it can be said that BFB has an acceptable effect in improving the symptoms of urinary and FEIN in women, although additional studies are needed to confirm the results.

Association Between Quality of Life and Neurogenic Bowel Symptoms by Bowel Management Program in Spina Bifida

OBJECTIVE

To compare differences in bowel-specific quality of life (QOL), overall qQOL, and neurogenic bowel dysfunction (NBD) severity by bowel management program in patients with spina bifida (SB).

METHODS

We performed a retrospective cross-sectional study of patients ≥12 years old at our multidisciplinary SB center who completed both a modified Peristeen NBD questionnaire (assessing bowel symptom severity and bowel-specific QOL) and the Patient-Reported Outcomes Measurement Information System Pediatric Global Health questionnaire (assessing overall QOL). Nested, multivariable models were fit for associations between outcomes and bowel management program (enemas, conservative management, and none).

RESULTS

A total of 173 patients, 56.1% female and 64.6% with myelomeningocele, were included in our analysis. Median age was 18.2 years old. Patients reported using enemas (n = 42), conservative management (n = 63), and no bowel program (n = 68). When adjusting for covariates, there was no significant association between bowel-specific QOL nor overall QOL across bowel management programs. However, the use of conservative management compared to enemas was associated with worse bowel symptoms severity (adjusted beta=2.58, 95%CI=[0.09,5.06]). Additionally, greater bowel symptom severity was significantly associated with lower overall QOL (adjusted beta=-0.33, 95%CI=[-0.57,-0.10]).

CONCLUSION

NBD symptom severity in SB is more strongly associated with QOL than the individual bowel program being utilized. Our findings suggest that different degrees of NBD require different invasiveness of bowel programs, but it is the outcome of the bowel management program and not the specific program itself that is most associated with QOL.

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.

Evaluation of functional gastrointestinal disorders in children aged 4-10 years with autism spectrum disorder

BACKGROUND

Gastrointestinal system disorders are known to be prevalent among children with autism spectrum disorder (ASD). Some ASD-associated comorbidities are abdominal pain, constipation, diarrhea, gastroesophageal reflux, sleep disturbances, epilepsy, and psychiatric problems. Nonetheless, there is still limited information about the presence of functional GI disorders (FGIDs) among children with ASD, especially in Türkiye. Using the Rome criteria, we aimed to investigate FGIDs in children with ASD.

METHODS

The sample of the study consisted of 68 children aged 4-10 years, diagnosed with ASD according to the DSM-5 diagnostic criteria and had scores greater than 30 on the Childhood Autism Rating Scale (CARS-2) and an age-sex matched control group (n=78). The Rome III criteria were used to evaluate FGIDs.

RESULTS

The frequency of FGIDs in the ASD group was higher (76.5%) compared to the control group (p < 0.001). Compared to the control group, abdominal migraine frequency increased 10 times (p=0.012), functional constipation 7 times (p < 0.001), and fecal incontinence 6 times (p < 0.001) in the ASD group. Stool retention was not present in most children in the ASD group who were found to have fecal incontinence.

CONCLUSION

In this study, the most common FGIDs in the ASD group were abdominal migraine, functional constipation, and non-retentive fecal incontinence. The finding that most children with ASD who had fecal incontinence did not show stool retention implicated social, psychological, and behavioral factors as the causes of incontinence. Raising awareness of healthcare professionals about the frequency of FGIDs in children with ASD will improve many areas in the daily lives of these children.

Developing a Cell-Microcarrier Tissue-Engineered Product for Muscle Repair Using a Bioreactor System

Fecal incontinence, although not life-threatening, has a high impact on the economy and patient quality of life. So far, available treatments are based on both surgical and nonsurgical approaches. These can range from changes in diet, to bowel training, or sacral nerve stimulation, but none of which provides a long-term solution. New regenerative medicine-based therapies are emerging, which aim at regenerating the sphincter muscle and restoring continence. Usually, these consist of the administration of a suspension of expanded skeletal-derived muscle cells (SkMDCs) to the damaged site. However, this strategy often results in a reduced cell viability due to the need for cell harvesting from the expansion platform, as well as the non-native use of a cell suspension to deliver the anchorage-dependent cells. In this study, we propose the proof-of-concept for the bioprocessing of a new cell delivery method for the treatment of fecal incontinence, obtained by a scalable two-step process. First, patient-isolated SkMDCs were expanded using planar static culture systems. Second, by using a single-use PBS-MINI Vertical-Wheel® bioreactor, the expanded SkMDCs were combined with biocompatible and biodegradable (i.e., directly implantable) poly(lactic-co-glycolic acid) microcarriers prepared by thermally induced phase separation. This process allowed for up to 80% efficiency of SkMDCs to attach to the microcarriers. Importantly, SkMDCs were viable during all the process and maintained their myogenic features (e.g., expression of the CD56 marker) after adhesion and culture on the microcarriers. When SkMDC-containing microcarriers were placed on a culture dish, cells were able to migrate from the microcarriers onto the culture surface and differentiate into multinucleated myotubes, which highlights their potential to regenerate the damaged sphincter muscle after administration into the patient. Overall, this study proposes an innovative method to attach SkMDCs to biodegradable microcarriers, which can provide a new treatment for fecal incontinence.

Efficacy of Pelvic Floor Muscle Training for Postoperative Patients With Rectal Cancer: A Systematic Review and Meta-Analysis

This study aimed to assess the effectiveness of pelvic floor muscle training (PFMT) for fecal incontinence (FI) and health-related quality of life (HR-QOL) after colorectal cancer surgery. This systematic review (SR) and meta-analysis included randomized controlled trials (RCTs) that examined the effects of PFMT after colorectal cancer surgery, which were extracted from several databases in January 2023. The primary outcomes were FI (Wexner scores), HR-QOL, and adverse events. We used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence (CoE). A total of seven RCTs were included. Our SR results suggested that PFMT showed little to no difference in FI (mean difference 0.62 higher; 95% CI: -1.26 to 2.5, low CoE) and adverse events (risk ratio 5.78; 95% CI: 0.28-117.22, low CoE). Two adverse events occurred in the PFMT group (anastomotic stenosis, suboptimal use of laxatives) and were not observed in controls. HR-QOL was measured in two RCTs using 12-item Short Form Survey (SF-12) and fecal incontinence quality of life (FIQL). Two RCTs found no trend toward a positive impact on HR-QOL. Higher quality RCTs on colorectal cancer after surgery are required. Furthermore, extending the duration of the PFMT intervention may be necessary to ensure its success.

Men and women experience different barriers to care seeking for fecal incontinence

BACKGROUND

Despite effective treatments for fecal incontinence (FI), FI remains underdiagnosed and undertreated. This study sought to characterize and compare rates of, delays in, experiences with, and barriers to care seeking for FI among men and women.

METHODS

This study was a secondary analysis of electronic survey data collected from adults with FI. The survey included the use of a validated instrument to assess FI severity and questions that now comprise a validated instrument for assessing barriers to care seeking for FI in women. Descriptive analyses characterized differences between men and women. χ2 testing for categorical variables and t-testing for normally distributed continuous variables compared statistical differences.

RESULTS

The sample (N = 548) was predominately female (84%), non-Hispanic White (90%), and insured (96%), with a mean Vaizey score (13.4 ± 5.3) consistent with moderate or severe FI. Care seeking rates (p = 0.81) and symptom duration before care seeking (p = 0.23) did not differ between women and men, but women were more likely than men to be told that effective treatments exist; most male and female respondents who sought care were offered treatment. Very few respondents had been asked about FI by a healthcare provider. Whereas normative thinking, limited life impact, and believing that a healthcare provider could not help were more common barriers to care seeking among men, avoidance, fear, and discouragement were more common in women.

CONCLUSIONS

Men and women with FI seek care at similar rates and after experiencing symptoms for a similar duration of time. Very few patients with FI have been screened for it by a healthcare provider. Barriers to FI care seeking are different for women and men, and men are less likely than women to be informed about effective treatments by a healthcare provider.

Fecal Incontinence after Severe Brain Injury: A Barrier to Discharge after Inpatient Rehabilitation?

BACKGROUND

In this study, we aimed to investigate the incidence of fecal incontinence (FI) after severe acquired brain injuries (sABIs) and to determine whether this symptom can lead to an inability to return home after rehabilitation.

METHODS

This was a retrospective observational cohort study. In total, 521 acute sABI inpatients were enrolled from the Department of Neurorehabilitation at an academic tertiary care hospital. Patients were divided into two groups, with and without FI, at the end of the rehabilitation phase. The primary and secondary endpoints were the incidence of persistent FI and any difference in the discharge destination.

RESULTS

Upon admission, new-onset FI was found in 443 (85%) patients, of which 38% had traumatic sABI. Moreover, 62.7% of all patients had FI upon admission. At discharge, 53.3% (264/495) of patients still had FI. Of these, 75.4% (199/264) had a Rancho Level of Cognitive Functioning Scale (LCFS) ≥3. A statistically significant correlation between FI at discharge and the presence of frontal lesions, autonomic crises, and increased LCFS scores was noted. Among the patients discharged to their homes, the proportion with persistent FI was lower (34% vs. 53.3).

CONCLUSIONS

FI was significantly persistent after sABI, even after recovery from unconsciousness, and must be considered as a consequence of, rather than an independent risk factor for, unfavorable outcomes.

Improving Bowel Function Recovery and Quality of Life in Han Chinese Patients with Spinal Cord Injuries: A Quantitative Assessment-Based Nursing Intervention Study

BACKGROUND Neurological bowel dysfunction (NBD) due to spinal cord injuries (SCIs) is common and significantly impacts patients' quality of life. This study evaluated the efficacy of quantitative assessment-based nursing interventions on bowel function recovery, quality of life, and caregivers' satisfaction with SCI patients with NBD. MATERIAL AND METHODS The study included 418 SCI patients with NBD. Patients were categorized into 3 cohorts: quantitative assessment-based nursing intervention (QN, n=114), conventional nursing intervention (CN, n=125), or no nursing intervention (DN, n=189). The 3 cohorts were followed over a 6-month period. RESULTS At 6 months post-intervention, patients in the QN and CN cohorts showed significant reductions in symptoms of fecal incontinence, constipation, and abdominal distension compared to the DN cohort. Additionally, defecation time decreased significantly in the QN and CN cohorts compared to both initial measures and the DN cohort. Notably, patients in the QN cohort demonstrated substantial improvement in overall quality of life scores compared to baseline, CN, and DN cohorts. The QN cohort also reported marked improvement in caregivers' satisfaction, surpassing that of caregivers in the CN and DN cohorts. CONCLUSIONS Six months of quantitative assessment-based nursing interventions significantly improved bowel function, quality of life, and caregiver satisfaction in SCI patients with NBD. This intervention appears beneficial for managing NBD in SCI patients and improving their quality of life and caregiver satisfaction.

Long-term Efficacy and Safety of Controlled Manual Anal Dilatation in the Treatment of Chronic Anal Fissures: A Single-center Observational Study

Objectives

Conventional anal dilatation for anal fissures has long been abandoned because of the high incidence of anal incontinence. However, less invasive and more precise dilation techniques have been developed that have shown high healing and low incontinence rates. This study aimed to evaluate the efficacy and safety of controlled anal dilatation (CAD) using a standardized maximum anal diameter.

Methods

This study included 523 patients who underwent CAD for chronic anal fissures between January 2010 and December 2014. CAD was performed under sacral epidural anesthesia. The index fingers of both hands were placed in the anus and dilated evenly in various directions. CAD was completed when the anus was dilated to the sixth scale (35 mm in diameter) using a caliber ruler.

Results

The mean anal scale size expanded from 3.1 to 5.8 (p<0.001). Non-healing was observed in nine patients (1.7%) at 1 month postoperatively, six of whom underwent additional CAD. The mean maximal anal resting pressure (mmHg) decreased from 90.2 to 79.7 at three months postoperatively (p<0.001). Postoperative complications were observed in 11 (2.1%) patients, of whom three patients with thrombosed hemorrhoids underwent resection. None of the patients complained of anal incontinence during the mean follow-up period of 16.6 months. The cumulative recurrence-free rates at three and five years were 87.9% and 69.2%, respectively.

Conclusions

CAD is technically simple and safe and can achieve reasonable long-term outcomes. Thus, CAD appears to be the preferred procedure for patients with chronic anal fissures who do not respond to conservative treatments.

Bowel dysfunctions after acquired brain injury: a scoping review

Bowel dysfunction is a common consequence of neurological diseases and has a major impact on the dignity and quality of life of patients. Evidence on neurogenic bowel is focused on spinal cord injury and multiple sclerosis; few studies have focused on patients with acquired brain injury (ABI). Neurogenic bowel dysfunction is related to a lifelong condition derived from central neurological disease, which further increases disability and social deprivation. The manifestations of neurogenic bowel dysfunction include fecal incontinence and constipation. Almost two out of three patients with central nervous system disorder have bowel impairment. This scoping review aims to comprehend the extent and type of evidence on bowel dysfunction after ABI and present conservative treatment. For this scoping review, the PCC (population, concept, and context) framework was used: patients with ABI and bowel dysfunction; evaluation and treatment; and intensive/extensive rehabilitation path. Ten full-text articles were included in the review. Oral laxatives are the most common treatment. The Functional Independence Measure (FIM) subscale is the most common scale used to assess neurogenic bowel disease (60%), followed by the Rome II and III criteria, and the colon transit time is used to test for constipation; however, no instrumental methods have been used for incontinence. An overlapping between incontinence and constipation, SCI and ABI increase difficulties to manage NBD. The need for a consensus between the rehabilitative and gastroenterological societies on the diagnosis and medical care of NBD.

Systematic review registration

Open Science Framework on August 16, 2022 https://doi.org/10.17605/OSF.IO/NEQMA.

Artificial Intelligence and Anorectal Manometry: Automatic Detection and Differentiation of Anorectal Motility Patterns-A Proof-of-Concept Study

INTRODUCTION

Anorectal manometry (ARM) is the gold standard for the evaluation of anorectal functional disorders, prevalent in the population. Nevertheless, the accessibility to this examination is limited, and the complexity of data analysis and report is a significant drawback. This pilot study aimed to develop and validate an artificial intelligence model to automatically differentiate motility patterns of fecal incontinence (FI) from obstructed defecation (OD) using ARM data.

METHODS

We developed and tested multiple machine learning algorithms for the automatic interpretation of ARM data. Four models were tested: k-nearest neighbors, support vector machines, random forests, and gradient boosting (xGB). These models were trained using a stratified 5-fold strategy. Their performance was assessed after fine-tuning of each model's hyperparameters, using 90% of data for training and 10% of data for testing.

RESULTS

A total of 827 ARM examinations were used in this study. After fine-tuning, the xGB model presented an overall accuracy (84.6% ± 2.9%), similar to that of random forests (82.7% ± 4.8%) and support vector machines (81.0% ± 8.0%) and higher that of k-nearest neighbors (74.4% ± 3.8%). The xGB models showed the highest discriminating performance between OD and FI, with an area under the curve of 0.939.

DISCUSSION

The tested machine learning algorithms, particularly the xGB model, accurately differentiated between FI and OD manometric patterns. Subsequent development of these tools may optimize the access to ARM studies, which may have a significant impact on the management of patients with anorectal functional diseases.

The use of a loose seton as a definitive surgical treatment for anorectal abscesses and complex anal fistulas

BACKGROUND

There is no consensus regarding the standard treatment method for anorectal abscesses accompanied by anal fistulas and complex anal fistulas. Simultaneous surgical treatment of the underlying anal fistula with anorectal abscess drainage is controversial due to incontinence problems.

OBJECTIVES

We aimed to investigate the effectiveness of the loose seton method for the treatment of chronic anal fistulas and acute anorectal abscesses accompanied by anal fistula.

MATERIAL AND METHODS

In this retrospective study, 114 patients who were operated on in our clinic due to chronic anal fistulas and anorectal abscesses with an applied loose seton between 2020 and 2022 were included in the study. The patients were divided into 2 groups: those with chronic complex anal fistula and those with anorectal abscess accompanied by anal fistula. The groups were compared in terms of their continence status, rate of recurrence, recurrent abscess formation, postoperative pain scores, duration of operation, and demographic characteristics.

RESULTS

Of the patients included in the study, 78 had a complex chronic anal fistula, and 36 had an anorectal abscess accompanied by an anal fistula. There were no differences between the demographic characteristics of the 2 groups. The mean seton dissociation time was 6.8 (3-19) months. Gas or stool leakage was not observed in patients during the mean follow-up period of 18 (6-30) months. There was no difference in postoperative continence levels between the 2 groups. No recurrent fistulas were observed in patients during the follow-up period. Recurrent abscesses were observed in 5 (13.9%) patients in the anorectal abscess group. Abscesses due to insufficient drainage were observed in 2 (2.6%) patients in the chronic fistula group. There was no significant difference in operation time between the 2 groups.

CONCLUSION

A loose seton can be a safe and effective method for the treatment of abscesses. It is a painless surgical method that produces good results in the treatment of all types of abscesses.

Anorectal Manometry in Patients With Fecal Incontinence After Ileal Pouch-Anal Anastomosis for Ulcerative Colitis: A Cohort Study

Background

Fecal incontinence commonly occurs in patients with ulcerative colitis and ileal pouch-anal anastomosis. There is a paucity of manometric data in pouch patients. We aimed to better define manometric parameters in pouch patients with fecal incontinence.

Methods

We compared clinical and manometric variables in ulcerative colitis patients with pouch and fecal incontinence to ulcerative colitis patients with pouch without fecal incontinence and to non-ulcerative colitis patients with fecal incontinence. Manometric data for the 3 cohorts were compared to established normative data. An independent-samples t-test was performed for continuous variables, and chi-square test was used for categorical variables. Logistic regression was performed to identify predictors of incontinence in pouch patients (P < .05).

Results

Among 26 pouch patients with fecal incontinence (73% female), 26 pouch patients without fecal incontinence (35% female), and 84 patients with fecal incontinence without ulcerative colitis (68% female), there were no differences in anorectal pressures between patients with fecal incontinence. Lower pressures were observed in pouch patients with fecal incontinence compared to those without fecal incontinence. Resting pressure was similar between pouch patients with fecal incontinence and healthy controls (60.9 ± 36.1 mmHg vs. 66.9 ± 3.2 mmHg, P = .40). Female sex (P = .019) and defecatory disorders (P = .033) each independently predicted fecal incontinence in pouch patients.

Conclusions

Pouch patients with fecal incontinence have lower anorectal pressures compared to pouch patients without incontinence, though have similar pressures to non-ulcerative colitis patients with fecal incontinence. Pouch patients with fecal incontinence have similar resting pressures as healthy controls. Distinct manometric normative values for pouch patients are needed.

State of the Art Bowel Management for Pediatric Colorectal Problems: Spinal Anomalies

BACKGROUND

Patients with spinal abnormalities often struggle with fecal and/or urinary incontinence (up to 87 and 92%, respectively) and require a collaborative approach to bowel management in conjunction.

METHODS

To define existing approaches and propose state-of-the-art bowel management, a literature search was performed using Medline/PubMed, Google Scholar, Cochrane, and EMBASE databases and focusing on the manuscripts published July 2013 and July 2023.

RESULTS

Patients with spinal anomalies have impaired innervation of the rectum and anal canal, decreasing the success rate from laxatives and rectal enemas. Thus, transanal irrigations and antegrade flushes are widely utilized in this group of patients. Based on spinal MRI, the potential for bowel control in these children depends on age, type, and lesion level. On referral for bowel management, a contrast study is performed to assess colonic motility and evacuation of stool, followed by a series of abdominal X-rays to define colonic emptying and adjust the regimen. The options for management include laxatives, rectal enemas, transanal irrigations, antegrade flushes, and the creation of a stoma. Approximately 22-71% of patients achieve social continence dependent on the type and level of the lesion.

CONCLUSION

Patients with spinal anomalies require a thorough assessment for continence potential and stool burden prior to initiation of bowel management. The optimal treatment option is defined according to the patient's age, anatomy, and mobility. The likelihood of independent bowel regimen administration should be discussed with the patients and their caregivers.

Clinical application of double-capsule fecal catheter device in ICU patients with fecal incontinence

OBJECTIVE

To explore and analyze the clinical effect and potential value of a double-capsule fecal catheter device in patients with fecal incontinence in the intensive care unit (ICU).

METHODS

A total of 107 patients with fecal incontinence who were admitted to the ICU of the First Affiliated Hospital of Gannan Medical University from May 2017 to April 2023 were selected and randomly divided into the observation group and the control group, with 68 cases in the observation group and 39 cases in the control group. The observation group was given a double-capsule fecal catheter device, and the control group was given an ordinary fecal catheter device for drainage. The clinical baseline data, adverse events, skin conditions, changes of patients' quality of life (QoL), indicators from laboratory test, working pressure and burden of nursing, average length of stay (ALOS) and prognosis of patients were compared between the two groups.

RESULTS

There was no significant difference in age, gender, body mass index (BMI), hypertension history, diabetes mellitus history and smoking history between the observation group and the control group (all P>0.05). The occurrence probability of the number of catheter obstructions, perianal leakage, catheter prolapse and the incidence of discomfort reactions in the observation group were significantly lower than those in the control group, and the difference was statistically significant (P<0.01). After the use of the double-capsule fecal catheter device, the skin condition of the patient's perineum and perianal area was significantly improved and remained dry and comfortable for a long time, and the recovery of the primary disease in patients with fecal incontinence was also more optimistic. After application of the double-capsule fecal catheter device, the scores of QoL significantly increased in patients from the observation group (P<0.05). After using the double-capsule fecal catheter device, the levels of WBC, neutrophils count, PCT and IL-6 in the observation group were significantly lower than those in the control group after nursing (P<0.05). However, there was no significant difference in levels of CRP, TNF-α, albumin and prealbumin between the two groups (P>0.05). The responsible nurses of the patients in the control group expressed significantly higher nursing work burden than the observation group (P<0.05). Patients in the observation group had shorter ALOS and lower mortality than those in the control group (P<0.01).

CONCLUSION

The application of the novel double-capsule fecal catheter device can reduce the adverse events and working pressure and burden of nursing, it also improved skin condition and patients' QoL. Correspondingly, it improved relevant prognostic indicators during the patient's hospitalization. It has beneficial clinical practicability and popularity for fecal incontinence in patients, and it is worthy of use and promotion.

Co-occurrence of fecal incontinence with constipation or irritable bowel syndrome indicates the need for personalized treatment

BACKGROUND

This study aimed to compare the prevalence and symptoms of fecal incontinence (FI) in relation to irritable bowel syndrome (IBS-associated FI), constipation (constipation-associated FI), and isolation (isolated FI).

METHODS

Data were analyzed from 3145 respondents without organic comorbidities known to influence defecation function from the general Chinese population who filled in the online Groningen Defecation and Fecal Continence questionnaire. FI, IBS, and constipation were evaluated with the Rome IV criteria.

KEY RESULTS

The prevalence of FI was 10.5% (n = 329) in the non-comorbidity group. After multivariable logistic regression analysis, IBS (odds ratio [OR]: 12.55, 95% confidence interval [CI]: 9.06-17.36) and constipation (OR: 4.38, 95% CI: 3.27-5.85) were the most significant factors contributing to FI. Based on this finding, 106/329 (32.2%) had IBS-associated FI, 119/329 (36.2%) had constipation-associated FI, and 104/329 (31.6%) had isolated FI. Among the 329 FI respondents, there was a high prevalence of IBS and constipation-related symptoms, including abdominal pain (81.5%) and abdominal bloating (77.8%) for IBS and straining during defecation (75.4%), incomplete defecation (72.3%), defecation blockage (63.2%), anal pain during defecation (59.3%), and hard stools (24%) for constipation. The patients with IBS-associated FI asked for specialists' help less frequently than those with isolated FI. Interestingly, among the patients with constipation-associated FI, 56.3% used anti-diarrhea medicine.

CONCLUSIONS AND INFERENCES

The prevalence of IBS-associated FI, constipation-associated FI, and isolated FI is comparably high. It is important to diagnose and target the cause of FI to provide personalized and cause-targeting care instead of treating only the FI symptoms.

Assessing Obstetric Anal Sphincter Injuries: A Comparison of Exoanal and Endoanal Ultrasound

OBJECTIVES

To explore the differences in assessing obstetric anal sphincter injuries (OASI) between transperineal ultrasound (TPUS) and endoanal ultrasound (EAUS) and test relationships between ultrasound findings and anal incontinence (AI) symptoms.

METHODS

A group of 196 women with a history of vaginal delivery was recruited. OASI was detected in a set of 5 slices by EAUS and 8 slices by TPUS. OASI grading was performed on TPUS rules and EAUS rules. A "significant sphincter defect" was diagnosed by TPUS and EAUS using "2/3 rules." Symptoms of AI were determined using the St Mark's Incontinence Score (SMIS). Ultrasound findings were compared between the two methods and correlated with symptoms.

RESULTS

Of 196 women, 29 (14.8%) suffered from AI with a mean SMIS of 12.1 ± 4.5, and 70 (35.7%) women with a mean age of 57 years had suspected OASI on imaging. Twenty-one (10.7%) "significant defects" were diagnosed by TPUS and 24 (12.2%) by EAUS. OASI Grades on TPUS had good agreement with EAUS rules (k = 0.70, P < .001). Logistic regression analysis showed that OASI Grade on imaging and "significant sphincter defects" seen on both forms of imaging were associated with AI symptoms. The odds ratio was 46 and 38 for "significant defects" on TPUS and EAUS, and 14 and 7 for OASI 3b+ on TPUS and EAUS in predicting AI, respectively.

CONCLUSIONS

"Significant defects" diagnosed by EAUS or TPUS and OASI Grade 3b+ predict AI symptoms. The diagnostic performance of endoanal and exoanal ultrasound (EAUS and TPUS) appear to be very similar.

Anal incontinence following obstetric anal sphincter injury: Is there a difference between subtypes? A systematic review

AIMS

Obstetric anal sphincter injury (OASI) is associated with long-term anal incontinence (AI). We aimed to address the following questions: (a) are women with major OASI (grade 3c and 4) at higher risk of developing AI when compared to women with minor OASI (grade 3a and 3b)? (b) is a fourth-degree tear more likely to cause AI over a third-degree tear?

METHODS

A systematic literature search from inception until September 2022. We considered prospective and retrospective cohort studies, cross-sectional and case-control studies without language restrictions. The quality was assessed by the Newcastle-Ottawa Scale and the Joanna Briggs Institute critical appraisal checklist. Risk ratios (RRs) were calculated to measure the effect of different grades of OASI.

RESULTS

Out of 22 studies, 8 were prospective cohort, 8 were retrospective cohort, and 6 were cross-sectional studies. Length of follow-up ranged from 1 month to 23 years, with the majority of the reports (n = 16) analysing data within 12-months postpartum. Third-degree tears evaluated were 6454 versus 764 fourth-degree tears. The risk of bias was low in 3, medium in 14 and high in 5 studies, respectively. Prospective studies showed that major tears are associated with a twofold risk of AI for major tears versus minor tears, while retrospective studies consistently showed a risk of fecal incontinence (FI) which was two- to fourfold higher. Prospective studies showed a trend toward worsening AI symptoms for fourth-degree tears, but this failed to reach statistical significance. Cross-sectional studies with long-term (≥5 years) follow-up showed that women with fourth-degree tear were more likely to develop AI, with an RR ranging from 1.4 to 2.2. Out of 3, 2 retrospective studies showed similar findings, but the follow-up was significantly shorter (≤1 year). Contrasting results were noted for FI rates, as only 5 out of 10 studies supported an association between fourth-degree tear and FI.

CONCLUSIONS

Most studies investigate bowel symptoms within few months from delivery. Data heterogeneity hindered a meaningful synthesis. Prospective cohort studies with adequate power and long-term follow-up should be performed to evaluate the risk of AI for each OASI subtype.

State of the Art Bowel Management for Pediatric Colorectal Problems: Hirschsprung Disease

After an initial pull-though, patients with Hirschsprung disease (HD) can present with obstructive symptoms, Hirschsprung-associated enterocolitis (HAEC), failure to thrive, or fecal soiling. This current review focuses on algorithms for evaluation and treatment in children with HD as a part of a manuscript series on updates in bowel management. In constipated patients, anatomic causes of obstruction should be excluded. Once anatomy is confirmed to be normal, laxatives, fiber, osmotic laxatives, or mechanical management can be utilized. Botulinum toxin injections are performed in all patients with HD before age five because of the nonrelaxing sphincters that they learn to overcome with increased age. Children with a patulous anus due to iatrogenic damage of the anal sphincters are offered sphincter reconstruction. Hypermotility is managed with antidiarrheals and small-volume enemas. Family education is crucial for the early detection of HAEC and for performing at-home rectal irrigations.

Study on 3D High-Resolution Anorectal Manometry Interrater Agreement in the Evaluation of Dyssynergic Defecation Disorders

Anorectal manometry measurements exhibit significant interrater variability. Newer techniques like 3D high-resolution anorectal manometry (3D-HRAM) have the potential to enhance diagnostic accuracy and our understanding of defecation disorders. However, the extent of interrater variability in 3D-HRAM is still unknown. Between January 2020 to April 2022, patients referred for pelvic floor physical therapy (PFPT) due to functional defecation complaints underwent 3D-HRAM testing. In a retrospective analysis, three expert raters independently evaluated the 3D-HRAM results in a blinded matter to assess interrater agreement. The evaluation also determined the level of agreement concerning dyssynergic patterns during simulated defecation. The 3D-HRAM results of 50 patients (37 females) were included. Twenty-nine patients had complaints of fecal incontinence, eleven patients had chronic constipation, and ten patients had several other complaints. There was a substantial agreement (kappa 0.612) between the raters concerning the 3D images on dyssynergic patterns during simulated defecation. Our study emphasizes the need for standardized guidelines in evaluating 3D-HRAM test results to reduce subjectivity and further improve agreement among raters. Implementing these guidelines could improve diagnostic consistency and enhance personalized treatment strategies, increasing the reliability and usefulness of 3D-HRAM testing in clinical practice.

Research on biomechanical compatibility for a novel artificial anal sphincter with constant force

BACKGROUND

Existing artificial anal sphincter studies have shown that biomechanical compatibility problem between artificial anal sphincter and rectum caused by long-term morphological changes of the tissue surrounding the implanted prosthesis can lead to device failure or tissue ischemic necrosis. In this article, a mechanical artificial anal sphincter with constant force clamping is designed based on the superelasticity of shape memory alloys, which improved the biomechanical compatibility of implantable artificial anal sphincter.

METHODS

Firstly, the anatomical structure and the biomechanical properties of the rectum are analyzed to obtain the size parameters and material parameters of the rectal model. Secondly, a novel artificial anal sphincter with constant force is designed to improve the biomechanical compatibility between the artificial sphincter and the rectum. Thirdly, the static analysis of artificial anal sphincter is carried out by finite element analysis.

RESULTS

The simulation results show that the artificial anal sphincter can maintain a constant clamping force of 4 N within a certain variation range of intestinal tissue thickness, which verifies the constant force characteristic of the artificial anal sphincter. The constant clamping force of the artificial anal sphincter to the rectum is 4 N that is greater than the clamping force 3.99 N required to close the rectum, which verifies the effectiveness the artificial anal sphincter. The surface contact stress and the minimum principal stress of the rectum in the clamping state are less than the pressure threshold, which verifies the safety of the artificial anal sphincter.

CONCLUSIONS

The novel artificial anal sphincter has better biomechanical compatibility and improves the mechanical match between artificial sphincter and intestinal tissue. This study may provide more reasonable and effective simulation data for in vivo experiments of artificial anal sphincter in future, which may provide theoretical and technical support for further research about clinical application of artificial anal sphincter.

Long-Term Outcomes of Antegrade Continence Enemas to Treat Constipation and Fecal Incontinence in Children

OBJECTIVES

The objective of this study is to investigate long-term outcomes of antegrade continence enema (ACE) treatment in children with constipation or fecal incontinence.

METHODS

Prospective cohort study including pediatric patients with organic or functional defecation disorders who started ACE treatment. Data were collected at baseline and at follow-up (FU) from 6 weeks until 60 months. We assessed parent and patient-reported gastrointestinal health-related quality of life (HRQoL) using the Pediatric Quality of Life Inventory Gastrointestinal Symptoms Module (PedsQL-GI), gastrointestinal symptoms, adverse events, and patient satisfaction.

RESULTS

Thirty-eight children were included (61% male, median age 7.7 years, interquartile range 5.5-12.2). Twenty-two children (58%) were diagnosed with functional constipation (FC), 10 (26%) with an anorectal malformation, and 6 (16%) with Hirschsprung disease. FU questionnaires were completed by 22 children (58%) at 6 months, 16 children (42%) at 12 months, 20 children (53%) at 24 months, and 10 children (26%) at 36 months. PedsQL-GI scores improved overall with a significant increase at 12- and 24-month FU for children with FC and a significant increase in parent reported PedsQL-GI score at 36-month FU for children with organic causes. Minor adverse events, such as granulation tissue, were reported in one-third of children, and 10% of children needed a surgical revision of their ACE. The majority of all parents and children reported that they would "probably" or "definitely" choose ACE again.

CONCLUSION

ACE treatment is perceived positively by patients and parents and can lead to long-term improvement in gastrointestinal HRQoL in children with organic or functional defecation disorders.

An Exploratory Study on the Contractile Effects of Hydroxy-α-Sanshool and Hydroxy-β-Sanshool, the Active Ingredients of Daikenchuto, on the Internal Anal Sphincter

Objectives

Daikenchuto (DKT) enhances the contraction of the internal anal sphincter (IAS) in patients with constipation and fecal incontinence; however, the mechanism of its action is unknown. We investigated the effects of the active ingredients of DKT (hydroxy-α-sanshool (HAS) and hydroxy-β-sanshool (HBS)) on the contractile activity of the canine rectum and IAS.

Methods

Three male beagle dogs were prepared for each of the HAS, HBS, and control groups. Force transducers were attached to the rectal and IAS surfaces of the dogs, and the contractile responses were measured by telemetry under conscious conditions. HAS (10 mg/body) and HBS (2.5 mg/body) were administered intrarectally at doses previously identified from an effective dose of DKT extract (1.5 g/body), and contractile responses were recorded up to 6 h after administration. Contractile activity of the rectum and IAS was evaluated by observing the area under the curve (AUC) of the recorded contraction waveform. Plasma concentrations of HAS and HBS were measured before and after administration to confirm IAS exposure to both ingredients.

Results

The mean AUC values of the IAS for the control, HAS, and HBS groups at 10 min after administration were 115, 87, and 220 (g-min), respectively, indicating a higher contraction in the HBS group, which was maintained for approximately 3 h. As for the rectum, no contractile response was observed in either the HAS or HBS groups. Plasma concentrations of both ingredients peaked at 20 min after administration.

Conclusions

HBS could be involved in the contractile action of DKT on the IAS.

Fecal incontinence and associated pelvic floor dysfunction during and one year after the first pregnancy

INTRODUCTION

Obstetric anal sphincter injury is an important risk factor for postpartum fecal incontinence but few studies have reported fecal incontinence occurring, even during pregnancy. The first objective of this study was to examine the prevalence of fecal incontinence, obstructed defecation and vaginal bulging early and late in pregnancy and postpartum. The second objective was to assess the association between symptoms in pregnancy, delivery characteristics, and bowel and vaginal bulging symptoms at 1 year postpartum.

MATERIAL AND METHODS

This prospective cohort study was conducted between October 2014 and October 2017, including 898 nulliparous women enrolled with the maternity healthcare service in Örebro County, Sweden. The women responded to questionnaires regarding pelvic floor dysfunction in early and late pregnancy and at 8 weeks and 1 year postpartum. The data were analyzed using random effect logistic models estimating odds ratios (ORs) and generalized linear models estimating relative risks, with 95% confidence intervals (CIs).

RESULTS

At 1 year postpartum, the prevalence of fecal incontinence, obstructed defecation and vaginal bulging was 6% (40/694), 28% (197/699) and 8% (56/695), respectively. Among women with vaginal delivery, the risk of fecal incontinence and vaginal bulging increased significantly both in late pregnancy, with ORs of 3.4 (95% CI 1.5-7.7) and 3.6 (95% CI 1.6-8.1), respectively, and at 1 year postpartum, with ORs of 5.0 (95% CI 2.1-11.5) and 8.3 (95% CI 3.8-18.1), respectively, compared with early pregnancy. Among all women, factors associated with increased prevalence of fecal incontinence 1 year postpartum were fecal incontinence during pregnancy (adjusted relative risk [aRR] 7.4; 95% CI 4.1-13.3), obstructed defecation during pregnancy (aRR 2.0; 95% CI 1.1-3.9) and concurrent obstructed defecation (aRR 2.4; 95% CI 1.3-4.5).

CONCLUSIONS

This prospective study shows an increased risk of fecal incontinence by late pregnancy, suggesting that the pregnancy itself may be involved in the development of postpartum fecal incontinence. Obstructed defecation during pregnancy and postpartum was found to be associated with increased risk of fecal incontinence postpartum, indicating that postpartum fecal incontinence may be a result of incomplete bowel emptying.

State of the Art Bowel Management for Pediatric Colorectal Problems: Functional Constipation

BACKGROUND

Functional constipation (FC) affects up to 32% of the pediatric population, and some of these patients are referred to pediatric surgery units to manage their constipation and/or fecal incontinence. The aim of the current paper is to report the recent updates on the evaluation and management of children with FC as a part of a manuscript series on bowel management in patients with anorectal malformations, Hirschsprung disease, spinal anomalies, and FC.

METHODS

A literature search was performed using Medline/PubMed, Google Scholar, Cochrane, and EMBASE databases and focusing on the manuscripts published within the last 5-10 years.

RESULTS

The first step of management of children with FC is to exclude Hirschsprung disease with a contrast study, examination under anesthesia, anorectal manometry (AMAN). If AMAN shows absent rectoanal inhibitory reflex, a rectal biopsy is performed. Internal sphincter achalasia or high resting pressures indicate botulinum toxin injection. Medical management options include laxatives, rectal enemas, transanal irrigations, and antegrade flushes. Those who fail conservative treatment require further assessment of colonic motility and can be candidates for colonic resection. The type of resection (subtotal colonic resection vs. Deloyer's procedure) can be guided with a balloon expulsion test.

CONCLUSION

Most of the patients with FC referred for surgical evaluation can be managed conservatively. Further studies are required to determine an optimal strategy of surgical resection in children unresponsive to medical treatment.

Evaluation of Anal Sphincter with High Resolution Anorectal Manometry and 3D Reconstruction in Patients with Anorectal Malformation

BACKGROUND

Patients with anorectal malformation (ARM) need long-term follow-up, in order to evaluate fecal continence; the main predictors of longer-term success are the type of ARM, associated anomalies and sacral integrity. Three-Dimensional High Resolution Anorectal Manometry (3D-HRAM) gives detailed information on pressure on the anal complex profile. Our objective was to analyze anal sphincter activity in ARM patients with 3D-HRAM establishing the correlation between manometric and clinical data.

METHODS

Forty ARM patients were submitted to 3D-HRAM: manometric, anatomical and clinical scores were correlated with each other and with the bowel management response (BM).

RESULTS

A positive correlation between all scores and types of ARM was found: in high ARM and in patients with spinal anomalies (regardless to ARM type) lower scores were reported and even after BM they did not achieve good continence.

CONCLUSIONS

3D-HRAM gives detailed data on the functional activity of the anal sphincter complex. Our study revealed a correlation between manometric parameters and clinical outcomes, confirming spinal malformations and ARM type as the most important prognostic risk factors for a bad outcome. Specific sphincteric defects can also be explored with manometry, allowing for tailored bowel management strategies.

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.

The incidence of anal incontinence following obstetric anal sphincter injury graded using the Sultan classification: a network meta-analysis

OBJECTIVE

This study aimed to systematically determine and compare the incidence of anal incontinence between those with different grades of obstetric anal sphincter injury.

DATA SOURCES

Ovid MEDLINE, Embase, and the Cochrane Library were searched from January 2000 to April 2021.

STUDY ELIGIBILITY CRITERIA

Observational studies investigating the incidence of anal incontinence following an obstetric anal sphincter injury that was graded using the Sultan classification were eligible for inclusion. To allow comparison between individual tear grades (3a, 3b, 3c, fourth), a network meta-analysis was performed using Stata (version 15.1).

METHODS

For binary outcomes, odds ratios with corresponding 95% confidence intervals were reported. Obstetric anal sphincter injury grades were ranked from the best clinical outcome to the worst clinical outcome. The percentage chance of each grade taking each rank with regards to outcome was calculated. Study quality and risk of bias was assessed using the relevant tool from the Joanna Briggs Institute.

RESULTS

Of the 696 studies identified, 10 were eligible for inclusion and were included in the network meta-analysis (n=2467 women). The mean incidence of anal incontinence among those with 3a tears was 22.4% (range, 6.1%-51.2%), 24.9% (range, 6.9%-46.7%) among those with 3b tears, 26.8% (range, 0%-55.6%) among those with 3c tears, and 28.6% (0%-71.4%) among those with fourth-degree tears. Anal incontinence incidence was found to be significantly higher among those with 3c (odds ratio, 1.79; 95% confidence interval, 1.09-2.94) and fourth-degree tears (odds ratio, 2.37; 95% confidence interval, 1.40-4.02) than among those with 3a tears. In addition, anal incontinence incidence was significantly higher among those with fourth-degree tears (odds ratio, 1.89; 95% confidence interval, 1.10-3.22) than among those with 3b tears. Those with 3a tears had the highest probability of having the best clinical outcome; those with 3b; second-, 3c; third- and fourth-degree tears had the highest probability of having the worst clinical outcome. Overall, all studies had a high or unclear risk of bias across 1 or more assessed element.

CONCLUSION

This was a network meta-analysis comparing the incidence of anal incontinence among those with different grades of obstetric anal sphincter injury. Increasing tear-grade severity is associated with worse clinical outcomes. This study provides useful, clinically applicable information that can assist clinicians in the counseling of women following an obstetric anal sphincter injury. In addition, it highlights the importance of accurately diagnosing the obstetric anal sphincter injury grade and subsequently performing the appropriate repair.

Cross-cultural adaptation and validation of the Korean version of the quality of life assessment in spina bifida for children (QUALAS-C-K)

PURPOSE

This study aimed to translate and cross-culturally adapt the QUAlity of Life Assessment in Spina bifida for Children (QUALAS-C) and validate the Korean version of the QUALAS-C (QUALAS-C-K).

MATERIALS AND METHODS

Three urologists translated the QUALAS-C into Korean. Facial and content validity were assessed in the pilot study. Back-translation into English was performed. In the main study, the QUALAS-C-K and Korean version of KIDSCREEN-27 were administered simultaneously. Test-retest reliability was confirmed by re-administering the QUALAS-C-K. Internal consistency was verified using Cronbach's alpha. Factor analysis was performed, and convergent and divergent validity were demonstrated using the Korean version of KIDSCREEN-27.

RESULTS

A total of 53 children with spina bifida participated in the main study. Cronbach's alpha for the overall instrument determined good internal consistency (0.72-0.85), the intraclass correlation coefficient showed good stability (0.74-0.77), and the factor analysis converged to the same two-factor structure as in the original version. Construct validity revealed weak-to-moderate associations (r ≤ 0.57) between QUALAS-C-K and K-KIDSCREEN-27, indicating that QUALAS-C-K measures different aspects of the HRQOL than K-KIDSCEEN-27.

CONCLUSIONS

The QUALAS-C-K is a reliable and valid instrument for assessing the health-related quality of life of children with SB in Korea.IMPLICATIONS FOR REHABILITATIONHealth-related quality of life (HRQOL) is an important patient-reported outcome among children with spina bifida (SB).The QUAlity of Life Assessment of Spina bifida for Children (QUALAS-C) is a self-reported, age-appropriate, and condition-specific HRQOL questionnaire for children with SB, developed in the United States.Our study demonstrated that the Korean version of the QUAlity of Life Assessment of Spina bifida for Children (QUALAS-C-K) is a valid and reliable tool.The QUALAS-C-K is a succinct and valuable questionnaire that can be used to assess HRQOL of children with SB, particularly focusing on bladder and bowel problems in clinical practice and research.

High amplitude propagated contractions with Glycerin versus Bisacodyl: A within-subject comparison in children undergoing colonic manometry

BACKGROUND

The presence of high amplitude propagated contractions (HAPCs) measured by colonic manometry (CM) reflect an intact neuromuscular function of the colon. Bisacodyl and Glycerin are colonic stimulants that induce HAPCs and are used for the treatment of constipation. HAPCs characteristics with each drug have not been compared before. We aimed to compare the HAPC characteristics with Bisacodyl and Glycerin in children undergoing CM for constipation.

METHODS

This is a prospective single-center cross-over study of children aged 2-18 years undergoing CM. All patients received both Glycerin and Bisacodyl during CM. They were randomized to group A with Bisacodyl first (n = 22) and group B with Glycerin first (n = 23), with 1.5 hours in between each dose. Differences in patient and HAPC characteristics between groups were summarized using descriptive statistics and compared using Chi-square test or Wilcoxon rank sum test as appropriate.

KEY RESULTS

A total of 45 patients were included. HAPCs post Bisacodyl had a longer duration of action (median of 40 vs 21.5 min, p < 0.0001), longer propagation (median of 70 vs 60 cm, p = 0.02), and more HAPCs (median of 10 vs 5, p < 0.0001) compared Glycerin. No differences were found in the HAPC amplitude and onset of action between both medications.

Pelvic floor investigations for anal incontinence: Are they useful to predict outcomes from conservative treatment?

AIMS

There are several options for treating anal incontinence (AI), with limited success rate in long-term follow-up. Patients' selection is important to avoid unnecessary investigations and therapies. The aim of this review is to assess the utility of pelvic floor investigations to predict success from conservative treatment in AI.

METHODS

Baseline demographics, severity scores, and pelvic floor investigations of 490 patients with AI symptoms were retrospectively reviewed. Patient-reported outcomes were used to define success of conservative treatment.

RESULTS

Bivariate analysis showed that gender, St Mark's incontinence score, Bowel continence and quality of life domains of International Consultation on Incontinence Modular Questionnaire-Bowel symptoms score, Bristol stool chart, anal squeeze pressure, enterocoele, leak of contrast at rest, and dyssynergia in defecography were associated with patient's outcomes from conservative treatment (p < 0.05). Multivariate analysis showed that only the Bowel continence score was an independent predictor of patient's success with treatment.

CONCLUSIONS

Pelvic floor investigations are of limited value to predict success of conservative treatment and they should be reserved for patients who fail noninvasive management and might require surgical intervention.

Artificial sphincters: An overview from existing devices to novel technologies

Artificial sphincters (ASs) are used to replace the function of the biological sphincters in case of severe urinary and fecal incontinence (UI and FI), and gastroesophageal reflux disease (GERD). The design of ASs is established on different mechanisms, e.g., magnetic forces or hydraulic pressure, with the final goal to achieve a implantable and durable AS. In clinical practice, the implantation of in-commerce AS is considered a reasonable solution, despite the sub-optimal clinical outcomes. The failure of these surgeries is due to the malfunction of the devices (between 46 and 51%) or the side effects on the biological tissues (more than 38%), such as infection and atrophy. Concentrating on this latter characteristic, particular attention has been given to the interaction between the biological tissues and AS, pointing out the closing mechanism around the duct and the effect on the tissues. To analyze this aspect, an overview of existing commercial/ready-on-market ASs for GERD, UI, and FI, together with the clinical outcomes available from the in-commerce AS, is given. Moreover, this invited review discusses ongoing developments and future research pathways for creating novel ASs. The application of engineering principles and design concepts to medicine enhances the quality of healthcare and improves patient outcomes. In this context, computational methods represent an innovative solution in the design of ASs, proving data on the occlusive force and pressure necessary to guarantee occlusion and avoid tissue damage, considering the coupling between different device sizes and individual variability.

Effects of testosterone treatment on anal sphincter damage repair in ovariectomized rats

BACKGROUND

Fecal incontinence (FI) generally occurs with anal sphincter damage caused by vaginal delivery in women, obvious FI can develop in the postmenopausal stage. This pelvic floor dysfunction has no rational medical therapeutic options. We investigated the effect of testosterone treatment on the anal sphincter structure, serum thiol/disulfide levels, uterine tissue, and body composition in female rats in an experimental menopause-FI model.

METHODS

The animal experiments were performed between September and November 2020 at Experimental Animal Application and Research Center, Afyon Kocatepe University, Afyonkarahisar, Turkey. Thirty-two female rats were divided into four groups: sham, saline, 10 mg/kg testosterone undecanoate, 100 mg/kg testosterone undecanoate. Except for the sham group, all the other groups underwent ovariectomy (OVE) to create a menopause model. Two weeks after this procedure, the FI model was created under general anesthesia in all rat groups. At the end of the experiment, the rats were placed under general anesthesia, weighed, and euthanized after recording the data. The anal sphincter region and uterine tissue samples were collected for histopathological examinations, and blood samples were collected for total testosterone and thiol/disulfide homeostasis analyses.

RESULTS

An increase in anal sphincter muscles and connective tissue thickness was observed in the testosterone-administered groups (p = 0.001). No difference was detected between the groups in the total thiol, native thiol, and disulfide balance (p = 0.087, p = 0.604, p = 0.092). The testosterone-treated groups did not have severe uterine epithelial degradation, hyperemia, or increased endometrial thickness (p = 0.186, p = 0.222, p = 0.630). The body weight of all rats increased (p < 0.05), but the omental weight did not increase (p = 0.061).

DISCUSSION

Testosterone treatment increased the anal sphincter muscle and connective tissue thickness without causing any oxidative stress and did not result in a pathological change in the uterine tissue and body fat composition.