Evaluation and treatment of constipation in children and adolescents

Childhood constipation is common and almost always functional without an organic etiology. Stool retention can lead to fecal incontinence in some patients. Often, a medical history and physical examination are sufficient to diagnose functional constipation. Further evaluation for Hirschsprung disease, a spinal cord abnormality, or a metabolic disorder may be warranted in a child with red flags, such as onset before one month of age, delayed passage of meconium after birth, failure to thrive, explosive stools, and severe abdominal distension. Successful therapy requires prevention and treatment of fecal impaction, with oral laxatives or rectal therapies. Polyethylene glycol-based solutions have become the mainstay of therapy, although other options, such as other osmotic or stimulant laxatives, are available. An increase in dietary fiber may improve the likelihood that laxatives can be discontinued in the future. Education is equally important as medical therapy and should include counseling families to recognize withholding behaviors; to use behavior interventions, such as regular toileting and reward systems; and to expect a chronic course with prolonged therapy, frequent relapses, and a need for close follow-up. Referral to a subspecialist is recommended only when there is concern for organic disease or when the constipation persists despite adequate therapy.

Injection of a sclerosing agent as first line treatment in anal fissure

BACKGROUND

In our institution, the first line treatment in acute anal fissures (AAF) or chronic anal fissures (CAF) is the injection of a sclerosing agent consisting of phenol, menthol and peanut oil (Phenomen®, Sterop laboratory, Belgium) under the fissure after a local anaesthesia. This retrospective study presents the technique of injection, evaluates its efficacy and demonstrates the minimal occurrence of complications, continence problems and recurrences.

METHODS

129 patients with an anal fissure were treated between January 2010 and June 2011. 124 patients were reviewed retrospectively. 109 patients benefited from a sclerosis in our outpatient clinic.

RESULTS

Of the 109 patients treated by a sclerosis, 58 had an AAF and 51 had a CAF. 53/58 AAF (91.4%) healed and 40/51 CAF (78.4%). Duration of pain after injection was 2 days or less in 55 cases (50.4%), 1 week or less in 35 cases (32.2%) and more than 1 week in 19 cases (17.4%). The complication rate was low (2.7%) : 2 necrosis of the skin and 1 abscess at the site of injection. The rate of troubles of continence was 2.7% : 2 cases of soiling and 1 case of incon-tinence for gas all resolving within a month. At the end of the study, a fissure had recurred in 17 patients (15.6%).

CONCLUSIONS

The injection of a sclerosing agent under the fissure is performed in the practitioner's office. Healing rates are high, complications and recurrences are low. This therapeutic option may be a good alternative to classical treatments in case of anal fissures.

Fecal incontinence in men: Causes and clinical and manometric features

AIM: To determine the causes and characteristics of fecal incontinence in men and to compare these features with those presented by a group of women with the same problem.

METHODS: We analyzed the medical history, clinical and manometric data from 119 men with fecal incontinence studied in our unit and compared these data with those obtained from 645 women studied for the same problem. Response to treatment was evaluated after 6 mo of follow-up.

RESULTS: Fifteen percent of patients studied in our unit for fecal incontinence were male. Men took longer than women before asking for medical help. Ano-rectal surgery was the most common risk factor for men related to fecal incontinence. Chronic diarrhea was present in more than 40% of patients in both groups. Decreased resting and external anal sphincter pressures were more frequent in women. No significant differences existed between the sexes regarding rectal sensitivity and recto-anal inhibitory reflex. In 17.8% of men, all presenting soiling, manometric findings did not justify fecal incontinence. Response to treatment was good in both groups, as 80.4% of patients improved and fecal incontinence disappeared in 13.2% of them.

CONCLUSION: In our series, it was common that men waited longer in seeking medical help for fecal incontinence. Ano-rectal surgery was the major cause of this problem. Chronic diarrhea was a predisposing factor in both sexes. Manometric differences between groups were limited to an increased frequency of hypotony of the external anal sphincter in women. Fecal incontinence was controllable in most patients.

[Constipation and fecal incontinence in the elderly]

Alterations of anorectal functions (constipation and fecal incontinence) are very frequent in the elderly. The patient's global evaluation with his past medical history, comorbidities, medications, as well as social environment and physical dependence, is more than ever necessary in this high risk population to guide the explorations and the medical care of these disorders.

Anorectal conditions: fecal incontinence

Although fecal incontinence occurs in all age groups, it is more common among older adults, especially nursing home residents, and it is more common among women than men. It often is associated with urinary incontinence. Etiologies are broadly categorized to include anatomic/physiologic changes due to trauma, surgery, vaginal deliveries, radiation, or disease states; neurologic disorders; drugs; and functional impairments. Evaluation is aimed at identifying etiologies, and scoring systems can be used to estimate severity and monitor outcomes. The first step in treatment is managing possible etiologies and implementing conservative measures, including increasing dietary fiber intake, using antidiarrheal drugs, removing fecal impactions, and using biofeedback. If these measures fail to control incontinence, further testing can characterize specific defects. Tests include endorectal ultrasound, anorectal manometry, and pudendal nerve terminal motor latency. After the defect is characterized, management options include injecting biocompatible material to bulk up a rectal sphincter with a defined defect, suture repair of sphincter defects, transfer of gracilis or gluteal muscle to create a new sphincter, implanting an artificial sphincter or neurostimulator, creating an ostomy through which retrograde enemas can be administered, and colostomy to prevent feces from reaching the rectum. Anal plugs are a last resort.

[A pilot study: correction of the levator hiatus using an anal sling as a surgical treatment of faecal incontinence]

INTRODUCTION

Faecal incontinence is a significantly depressing and mentally devastating disability. Surgical treatment, as a first choice method, is indicated for incontinence originating as a result of traumatic or iatrogenic infliction of the sphincter apparatus, particularly of the external sphincter. In case of idiopathic (neurogenic) incontinence, it is indicated very exceptionally, if ever. The authors present a pilot study to verify the possibility of surgical treatment of anal incontinence with the support of a puborectal muscle loop by means of the absorbable STRATASIS® TF mesh.

MATERIAL AND METHODS

In the years 2010-2012, eight experimental surgical procedures were performed. Female patients with a history of faecal incontinence of the third stage longer than one year and with EMG-verified neurological lesion were recruited. The evaluating criteria were the Wexner score and changes in the levator and anorectal angle acquired from a MR defecographic examination performed before and six months after the operation.

RESULTS

The complaints improved distinctly in six patients; in the two remaining cases, the method failed completely. The failures were associated with an inflammatory complication in both cases. In one patient, the authors do not rule out an incorrect indication, too. The Wexner score decreased from 18 to 10 in improved patients. Changes in the levator and anorectal angle were not significant.

CONCLUSION

The results confirm the possibility of successful surgical influence on incontinence of the third stage by correcting the levator hiatus with biodegradable mesh. Continence improvement persists even after the mesh transforms into scar tissue.

Anorectal physiology and pathophysiology in the elderly

Anorectal medical disorders facing the elderly include fecal incontinence, fecal impaction with overflow fecal incontinence, chronic constipation, dyssynergic defecation, hemorrhoids, anal fissure, and pelvic floor disorders. This article discusses the latest advances in age-related changes in morphology and function of anal sphincter, changes in cellular and molecular biology, alterations in neurotransmitters and reflexes, and their impact on functional changes of the anorectum in the elderly. These biophysiologic changes have implications for the pathophysiology of anorectal disorders. A clear understanding and working knowledge of the functional anatomy and pathophysiology will enable appropriate diagnosis and treatment of these disorders.

An update on anorectal disorders for gastroenterologists

Gastroenterologists frequently encounter pelvic floor disorders, which affect 10% to 15% of the population. The anorectum is a complex organ that collaborates with the pelvic floor muscles to preserve fecal continence and enable defecation. A careful clinical assessment is critical for the diagnosis and management of defecatory disorders and fecal incontinence. Newer diagnostic tools (eg, high-resolution manometry and magnetic resonance defecography) provide a refined understanding of anorectal dysfunctions and identify phenotypes in defecatory disorders and fecal incontinence. Conservative approaches, including biofeedback therapy, are the mainstay for managing these disorders; new minimally invasive approaches may benefit a subset of patients with fecal incontinence, but more controlled studies are needed. This mini-review highlights advances, current concepts, and controversies in the area.

[Surgical treatment of patients with severe fecal incontinence]

The objective of the study is improvement of clinical and functional results of surgical treatment of patients with severe fecal incontinence. 79 patients with complete fecal incontinence were included in the study. The technique of surgical intervention was choosed in depending on the localization of structural and functional disorders of the rectum closing apparatus. Complex treatment in pre-operative and post-operative periods was directed on the improvement of functional results. Long-term results (6-24 months) were traced in 63 patients after surgical treatment and complex post-operative rehabilitation. Good and satisfactory results were identified in 57 (90.5%) patients, unsatisfactory results - in 6 (9.5%) patients. Choice of surgical technique in depending on the localization of structural and functional disorders of the rectum closing apparatus and combination of surgical correction with complex functional rehabilitation allow to increase treatment efficiency. Also it improves closing function in the most patients.

Posterior tibial nerve stimulation for fecal incontinence: Where are we?

Neurostimulation remains the mainstay of treatment for patients with faecal incontinence who fails to respond to available conservative measures. Sacral nerve stimulation (SNS) is the main form of neurostimulation that is in use today. Posterior tibial nerve stimulation (PTNS) - both the percutaneous and the transcutaneous routes - remains a relatively new entry in neurostimulation. Though in its infancy, PTNS holds promise to be an effective, patient friendly, safe and cheap treatment. However, presently PTNS only appears to have a minor role with SNS having the limelight in treating patients with faecal incontinence. This seems to have arisen as the strong, uniform and evidence based data on SNS remains to have been unchallenged yet by the weak, disjointed and unsupported evidence for both percutaneous and transcutaneous PTNS. The use of PTNS is slowly gaining acceptance. However, several questions remain unanswered in the delivery of PTNS. These have raised dilemmas which as long as they remain unsolved can considerably weaken the argument that PTNS could offer a viable alternative to SNS. This paper reviews available information on PTNS and focuses on these dilemmas in the light of existing evidence.

Current management of fecal incontinence: Choosing amongst treatment options to optimize outcomes

The severity of fecal incontinence widely varies and can have dramatic devastating impacts on a person’s life. Fecal incontinence is common, though it is often under-reported by patients. In addition to standard treatment options, new treatments have been developed during the past decade to attempt to effectively treat fecal incontinence with minimal morbidity. Non-operative treatments include dietary modifications, medications, and biofeedback therapy. Currently used surgical treatments include repair (sphincteroplasty), stimulation (sacral nerve stimulation or posterior tibial nerve stimulation), replacement (artificial bowel sphincter or muscle transposition) and diversion (stoma formation). Newer augmentation treatments such as radiofrequency energy delivery and injectable materials, are minimally invasive tools that may be good options before proceeding to surgery in some patients with mild fecal incontinence. In general, more invasive surgical treatments are now reserved for moderate to severe fecal incontinence. Functional and quality of life related outcomes, as well as potential complications of the treatment must be considered and the treatment of fecal incontinence must be individualized to the patient. General indications, techniques, and outcomes profiles for the various treatments of fecal incontinence are discussed in detail. Choosing the most effective treatment for the individual patient is essential to achieve optimal outcomes in the treatment of fecal incontinence.

Neuromodulation for fecal incontinence: An effective surgical intervention

Fecal incontinence is a disabling symptom with medical and social implications, including fear, embarrassment, isolation and even depression. Most patients live in seclusion and have to plan their life around the symptom, with secondary impairment of their quality of life. Conservative management and biofeedback therapy are reported to benefit a good percentage of those affected. However, surgery must be considered in the non-responder population. Recently, sacral nerve electrostimulation, lately named neuromodulation, has been reported to benefit patients with fecal incontinence in randomized controlled trials more than placebo stimulation and conservative management, by some unknown mechanism. Neuromodulation is a minimally invasive procedure with a low rate of adverse events and apparently favorable cost-efficacy profile. This review is intended to expand knowledge about this effective intervention among the non-surgically skilled community who deals with this disabled group of patients.

[Pelvic floor disorders from the surgeon's viewpoint]

Pelvic floor disorders present very differently with regard to symptoms and manifestation. Both diagnostic and treatment options require specific experience and an interdisciplinary approach. Diagnostic work-up is primarily based on medical history, physical examination and procto-rectoscopy. Furthermore, endosonography and perineal sonography have also gained importance. In almost all cases following these basic examinations conservative therapy options should be considered. As the interdisciplinary concept is very important, for careful diagnosis of pelvic floor disorders it became crucial to find an adequate form of treatment. Every decision for surgical therapy should not only focus on the results of previous examinations but should also consider the individual situation of each patient. In pelvic floor disorders a large variety of symptoms are confronted with a vast number of different and often highly specific procedures. The decisions on who to treat and how to treat are not only based on individual patient requests and desires but also on the experience and preference of the surgeon.

First diagnosis and management of incontinence in older people with and without dementia in primary care: a cohort study using The Health Improvement Network primary care database

BACKGROUND

Dementia is one of the most disabling and burdensome diseases. Incontinence in people with dementia is distressing, adds to carer burden, and influences decisions to relocate people to care homes. Successful and safe management of incontinence in people with dementia presents additional challenges. The aim of this study was to investigate the rates of first diagnosis in primary care of urinary and faecal incontinence among people aged 60-89 with dementia, and the use of medication or indwelling catheters for urinary incontinence.

METHODS AND FINDINGS

We extracted data on 54,816 people aged 60-89 with dementia and an age-gender stratified sample of 205,795 people without dementia from 2001 to 2010 from The Health Improvement Network (THIN), a United Kingdom primary care database. THIN includes data on patients and primary care consultations but does not identify care home residents. Rate ratios were adjusted for age, sex, and co-morbidity using multilevel Poisson regression. The rates of first diagnosis per 1,000 person-years at risk (95% confidence interval) for urinary incontinence in the dementia cohort, among men and women, respectively, were 42.3 (40.9-43.8) and 33.5 (32.6-34.5). In the non-dementia cohort, the rates were 19.8 (19.4-20.3) and 18.6 (18.2-18.9). The rates of first diagnosis for faecal incontinence in the dementia cohort were 11.1 (10.4-11.9) and 10.1 (9.6-10.6). In the non-dementia cohort, the rates were 3.1 (2.9-3.3) and 3.6 (3.5-3.8). The adjusted rate ratio for first diagnosis of urinary incontinence was 3.2 (2.7-3.7) in men and 2.7 (2.3-3.2) in women, and for faecal incontinence was 6.0 (5.1-7.0) in men and 4.5 (3.8-5.2) in women. The adjusted rate ratio for pharmacological treatment of urinary incontinence was 2.2 (1.4-3.7) for both genders, and for indwelling urinary catheters was 1.6 (1.3-1.9) in men and 2.3 (1.9-2.8) in women.

CONCLUSIONS

Compared with those without a dementia diagnosis, those with a dementia diagnosis have approximately three times the rate of diagnosis of urinary incontinence, and more than four times the rate of faecal incontinence, in UK primary care. The clinical management of urinary incontinence in people with dementia with medication and particularly the increased use of catheters is concerning and requires further investigation. Please see later in the article for the Editors' Summary.

[Direct sphincter repair: techniques, indications and results]

L'incontinence anale est un handicap physique, psychique et social majeur qui a de nombreuses causes différentes. Les méthodes actuellement disponibles pour améliorer les symptômes de cette incontinence sont les méthodes médicales et de rééducation d'une part et les méthodes chirurgicales d'autre part. Quatre techniques chirurgicales répondent à ces objectifs pour la plupart des malades: la sphinctérorraphie, la neuromodulation des racines sacrées, et les deux techniques de substitution que sont le sphincter artificiel et la graciloplastie dynamisée. La réparation sphinctérienne directe est la technique la plus utilisée dans le traitement chirurgical de l'incontinence anale (IA) par lésion sphinctérienne. Cette technique est envisageable chez les malades ayant une incontinence fécale en rapport avec des lésions limitées du sphincter anal externe. La technique chirurgicale est simple (myorraphie par suture directe ou en paletot) et bien codifiée. Les résultats fonctionnels sont imparfaits et se dégradent avec la durée du suivi. Une continence parfaite après réparation sphinctérienne est rarement acquise de façon durable: le malade candidat à cette approche thérapeutique doit en être averti.

[Practical approach to constipation in adults]

The authors present epidemiology etiology pathophysiology management, and treatment of constipation including proper qualification for surgery. Constipations can be divided into more common - primary and less frequent - secondary The latter may occur due to organic lesions of the large bowel, in the course of metabolic and endocrine disorders, or neurological and psychiatric diseases. Constipation may also be a side effect of multiple medications. In turn, primary constipation is either a slower movement of contents within the large bowel or twice as likely pelvic floor dysfunction with the inability to adequately evacuate the contents from the rectum. Symptoms such as infrequent defecation and decreased urge to defecate indicate rather colonic inertia whereas prolong straining even in case of loose stools, and feeling of incomplete evacuation are typical of obstructed defecation. Digital rectal examination reveals common anorectal defects presenting with constipation such as tumors, anal fissures and strictures, and rectocele, or less frequent changes such as rectal intussusception and enterocele. Proctologic examination should include the assessment of the anal sphincter tone and the pelvic floor movement. Barium enema or colonoscopy are necessary to confirm or exclude colorectal organic lesions, mostly in patients with alarm features. More accurate differentiation between slow transit constipation and obstructed defecation is possible with tests such as colonic transit time, defecography and anorectal manometry Treatment of constipation, irrespective of the cause, is initiated with lifestyle modification which includes exercise, increased water intake and a high-fiber diet. Pharmacologic treatment is started with osmotic agents followed by stimulant laxatives. In turn, biofeedback therapy is a method of choice for the treatment of defecation disorders. There is a small group of patients with intractable slow-transit constipation and descending perineum syndrome who require surgery Surgical treatment is also indicated in patients with symptomatic rectocele, and advanced rectal intussusception. Enterocele can be corrected during perineopexy performed for the descending perineum.

Evaluating the patient with diarrhea: a case-based approach

The evaluation of the patient with diarrhea can be complex and the treatment challenging. In this article, the definition of diarrhea and the pathophysiologic mechanisms that lead to diarrhea are reviewed. A simplified 5-step approach to the patient with diarrhea is provided and applied in a case-oriented manner applicable to everyday clinical practice. On completion of this article, you should be able to (1) define diarrhea, (2) outline various pathophysiologic mechanisms of diarrhea, and (3) describe a simplified 5-step approach to facilitate the evaluation of diarrhea.

Recognition and management of nonrelaxing pelvic floor dysfunction

Nonrelaxing pelvic floor dysfunction is not widely recognized. Unlike in pelvic floor disorders caused by relaxed muscles (eg, pelvic organ prolapse or urinary incontinence, both of which often are identified readily), women affected by nonrelaxing pelvic floor dysfunction may present with a broad range of nonspecific symptoms. These may include pain and problems with defecation, urination, and sexual function, which require relaxation and coordination of pelvic floor muscles and urinary and anal sphincters. These symptoms may adversely affect quality of life. Focus on the global symptom complex, rather than the individual symptoms, may help the clinician identify the condition. The primary care provider is in a position to intervene early, efficiently, and effectively by (1) recognizing the range of symptoms that might suggest nonrelaxing pelvic floor dysfunction, (2) educating patients, (3) performing selective tests when needed to confirm the diagnosis, and (4) providing early referral for physical therapy.

[The ethiology, pathogenesis, diagnostics and clinical features of the complicated posttraumatic rectal fistulae]

The ethiology, pathogenesis, diagnostics, clinical features and the capabilities of modern instrumental methods in the diagnosis of 134 patients with posttraumatic rectal fistulaes. The main causes of the rectal fistulae formation was the mechanism of the forecoming trauma, late hospital admission and postoperative complications. The use of modern diagnostic facilities allows to know the anatomic features of the fistulae, the presence of the septic cavities of the pararectal tissue, the involvement of sphincter muscles to the inflammatory process and their functional state. All the listed above facilitate the efficacy of the surgical treatment.

Accuracy of the digital anal examination in women with fecal incontinence

INTRODUCTION AND HYPOTHESIS

This study aims to determine the accuracy of digital rectal examination (DRE) to detect anal sphincter defects when compared to endoanal ultrasound (US) in women with fecal incontinence (FI).

METHODS

Seventy-four patients identified by retrospective chart review who presented with complaints of bothersome FI who underwent endoanal US are the subjects of this analysis. Sensitivity, specificity, and positive and negative likelihood ratios were calculated for the ability of the DRE to detect anal sphincter defects.

RESULTS

Anal sphincter defect was suspected on DRE in 75%. At endoanal US, external sphincter defects were noted in all three segments in 41% (complete defect) while partial defects were noted in 30%. DRE demonstrated a sensitivity of 82%, specificity of 32%, +likelihood ratio 1.2 (95% confidence interval (CI), 0.95-1.16) and -likelihood ratio of 0.6 (95% CI, 0.2-1.24) for detecting a complete EAS defect on endoanal US.

CONCLUSION

DRE has poor specificity for detecting anal sphincter defects seen on endoanal US.

Coexistence of constipation and incontinence in children and adults

The coexistence of constipation and fecal incontinence has long been recognised in paediatric and geriatric populations, but is grossly underappreciated in the rest of the adult population. In children, functional fecal incontinence is usually associated with constipation, stool retention and incomplete evacuation, and is frequently allied to urinary incontinence. Pathophysiology of the incontinence is incompletely understood, although both in children and adults, it is thought to be secondary to overflow, while in adults it may also be related to pelvic floor dysfunction and denervation. Incontinence has an important impact on quality of life and daily functioning, and in children may be associated with behaviour problems. The treatment of underlying constipation usually results in improvement in incontinence. This review broadly addresses the epidemiology and pathophysiology of coexistent constipation and incontinence in both children and adults, and also reviews clinical presentation and treatment response in pediatrics.

Utility preference score measurement in women with fecal incontinence

OBJECTIVE

The objective of the study was to evaluate the construct validity of 3 multiattribute health status classification system instruments, and a visual analog scale (VAS) for measuring utility scores for women with fecal incontinence (FI).

STUDY DESIGN

Utility scores were measured in 200 women with 1 or more of the following diagnoses: fecal or urinary incontinence or pelvic organ prolapse. Pelvic floor symptom severity was measured using the Pelvic Floor Distress Inventory (PFDI-20), and quality of life was assessed with the Pelvic Floor Impact Questionnaire (PFIQ-7). Construct and concurrent validity were evaluated.

RESULTS

After adjusting for age, comorbidities, urinary incontinence, and prolapse, utility scores were significantly lower for women with FI than women without FI for all health status instruments but not the VAS. All health status instruments had significant correlations with PFDI-20 and PFIQ-7 scores.

CONCLUSION

The health status instruments provide valid utility scores in women with FI and would be useful in clinical trials and cost-effectiveness research.

Fecal incontinence: part 4 of a series of articles on incontinence

BACKGROUND

The aging of the population will make fecal incontinence an increasingly important socioeconomic problem in the coming decades. Already today, the cost to society of treating incontinence with inserts, diapers, and closed systems exceeds the total cost of all cardiac and anti-inflammatory medications.

METHODS

This article is based on a selective review of the literature and on clinical experience. No meta-analyses on this topic have yet been published.

RESULTS

Surveys in highly industrialized countries in the Western Hemisphere have shown that about 5% of the population suffers from fecal incontinence of varying degrees of severity. This condition will become more common, in both relative and absolute terms, in the coming decades. Various methods of care and therapy are currently available for fecal incontinence, yet many patients do not seek medical help for it because of embarrassment. Thus, its true prevalence is certainly higher than the surveys imply.

CONCLUSION

The challenge today, therefore, is not just to encourage patients to seek medical help early, but also to raise physicians' awareness of fecal incontinence and their readiness to treat it, so that they can provide competent individual counseling and treatment to all patients who suffer from it.

Postnatal pelvic floor dysfunction: conservative treatment and management options

Thirty per cent of postnatal women will suffer with one or more symptoms of pelvic floor dysfunction. Left untreated, symptoms can lead to social isolation and embarrassment. Long-term co-morbidity is increased in women who have symptoms of pelvic floor dysfunction postnatally, therefore assessing and treating these symptoms when they develop is crucia for the wellbeing of women. This article describes the key issues in the identification, assessment and conservative management of women with pelvic floor dysfunction in the postnatal period.

The effects of biofeedback training of pelvic floor muscles on fecal incontinence

OBJECTIVE

The purpose of this study is to discuss the effect of pelvic floor muscle training on fecal incontinence.

METHODS

A retrospective study was performed on patients who received pelvic floor muscle training from March 2002 to April 2007. There were 55 patients with fecal incontinence (male, 32 cases; female, 23 cases; mean age, 9.4 years old from 6 to 14), including 39 cases of anorectal malformation and 16 cases of Hirschsprung's disease. Pelvic floor muscle training was performed using biofeedback for 2 weeks in hospital, 2 times each day, and 30 minutes each time. The patients were then instructed to carry out self-training at home without the biofeedback device daily and received training evaluations in the hospital outpatient department monthly. All patients completed the training regimen and were followed up for 1 year. Anal manometry and clinical score were evaluated before and after training.

RESULTS

Anal continence of 30 patients had satisfactory improvement, but not for the other 25 cases after training. The mean anal squeeze pressures of the group that had good results and the group that had poor results were 98.4 +/- 7.3 and 47.4 +/- 13.6 mm Hg, respectively, before training. There were 31 patients whose anal squeeze pressures were above 80 mm Hg, and 26 of these had satisfactory anal continence improvement, including all patients with Hirschsprung's disease. On the contrary, only 4 of 24 cases whose anal squeeze pressure was below 80 mm Hg acquired satisfactory anal continence improvement.

CONCLUSIONS

Pelvic floor muscle training could achieve good results in some patients with fecal incontinence. Baseline measurements during anorectal manometry appear to provide good prediction of prognosis and effective management.

Discriminative value of anorectal manometry in clinical practice

Guidelines recommend anorectal manometry in patients with fecal incontinence and chronic constipation. However, limited evidence supports the utility of manometric testing. We retrospectively reviewed tracings obtained between November 2005 and May 2008. A total of 298 patients (86% women; average age 52 years) were included. The main indications were incontinence (51%) and constipation (42%). Patients suffering from incontinence were older and had lower resting and squeeze pressure compared to continent patients. However, the discriminative power of manometric pressure data was poor, with low sensitivity and specificity. An abnormal straining pattern suggesting dyssynergic defecation was seen in 43% of constipated patients compared to 13% of patients with fecal incontinence. A concordance between manometric patterns and the balloon expulsion test was seen in 72%. The low sensitivity and specificity of manometric parameters does not support the routine use of anorectal manometry in patients with defecation disorders.

Common anorectal disorders: diagnosis and treatment

Anorectal disorders affect men and women of all ages. Their management is not limited to the evaluation and treatment of hemorrhoids. Rather, a spectrum of anorectal disorders ranges from benign and irritating (pruritus ani) to potentially life-threatening (anorectal cancer). Symptoms are nonspecific, which can make the evaluation of patients difficult. In addition, treatment can be frustrating because clinicians are hamstrung by a lack of well-designed, prospective, clinical trials. Some of the most common anorectal disorders include fecal incontinence, pelvic floor dyssynergia, anal fissures, pruritus ani, proctalgia fugax, and solitary rectal ulcer syndrome. This article provides an update on the evaluation and treatment of common anorectal disorders.

Reliability of assessment of urgency and other symptoms indicating anal sphincter, large bowel or urinary dysfunction

OBJECTIVE

The Radiumhemmets Scale of Disease-Specific Symptom Assessment-Prostate Cancer has been used in several studies. However, no test-retest reliability study of it has been conducted concerning the assessment of urinary, anal sphincter or large bowel function. The aim of this study was to evaluate the reliability of items assessing these functions.

MATERIAL AND METHODS

We investigated 89 prostate cancer patients randomly selected from a group of patients diagnosed in Stockholm. The patients answered 24 questions assessing anal sphincter, large bowel and urinary function twice, with a 3-week interval in-between, to assess reliability.

RESULTS

Most of the questions assessing bowel and urinary symptoms showed substantial or near-perfect agreement. The kappa value for bowel symptom items was > or = 0.60 for all items, except for defecation urgency (0.40-0.55). The kappa value for urinary symptom items varied between 0.43 and 1.0, except for urinary urgency (0.30-0.39).

CONCLUSIONS

When comparing the impact of different symptoms of anal sphincter, large bowel or urinary tract dysfunction, it may be important to consider that defecation urgency and urinary urgency have the highest measuring error (low reliability). This error dilutes assessed associations with, for example, decreased quality of life. Nevertheless, the test-retest reliability for anal sphincter, large bowel and urinary symptoms indicates that surveys yield meaningful information.

Double-loop puborectoplasty: novel technique for the treatment of fecal incontinence

The treatment of neurogenic and traumatic fecal incontinence (FI) as may result from severe anal sphincteric destruction is problematic. A novel technique for the treatment of these cases is presented. The study comprised 44 patients, which included 28 with neurogenic and 16 with traumatic FI. Patients were divided into two equal groups. Two fascia lata slings (FLS) were applied in Group 1, while one sling was used in Group 2. Investigations comprised manometric and electromyographic studies. The procedure consisted of performing a curvilinear incision behind the anal orifice, and the supralevator region was entered. The middle of an FLS was sutured to the back of the upper part of anal canal. Each of the two limbs of the sling was passed forward through an incision on the pubic ramus and was sutured to the periosteum of the pubic ramus. This was preformed in Groups 1 and 2. A second FLS was added in Group 1. Its center was sutured to the front of the mid anal canal and its two limbs to the coccyx. Satisfactory results (continence scores 1 and 2) were obtained in 63.6% of Group 1 and 36.4% of Group 2. Significant postoperative anal pressure increase occurred in scores 1 to 3 in Group 1 and in scores 1 to 2 in Group 2. Anal pressure increase was more prominent in Group 1 than in Group 2. The continent effect of the operation appears to be due to the increase of anal pressure, anal canal elongation, and recto-anal angulation. The operation is indicated in FI of the idiopathic or traumatic type with excessive sphincteric loss. It is simple and easy and performed under no cover of colostomy.

[Treatment of functional diseases after rectum anal surgery: effectiveness of rehabilitation of the pelvic pavement]

AIM

Anorectal dysfunction is routinely treated at the Center for Pelvic Floor Rehabilitation, San Giovanni University Hospital, Turin, Italy. Of a total of 147 patients treated between April 2007 and May 2008, 44 (30%) received pelvic floor rehabilitation following anorectal surgery. With this study we wanted to evaluate the response of patients with constipation and/or fecal incontinence to postsurgical pelvic floor rehabilitation designed to regain full or partial anorectal function and so improve their quality of life.

MATERIAL AND METHODS

The study population was 44 patients, subdivided into 3 groups. One group (n=25) consisted of patients with fecal incontinence, which was further split into two subgroups: subgroup A (n=10) with direct involvement of the anal sphincter at surgery and subgroup B (n=15) without sphincter involvement. The second group (n=12) included patients with constipation. The third group (n=7) included patients with constipation and incontinence; this group was further split into 2 subgroups: those in which constipation (n=5) and those in which incontinence (n=2) was predominant. Pre- and postrehabilitation anorectal function was compared using two types of assessment: 1) clinical evaluation with the Wexner incontinence scale and 2) diagnostic evaluation with anorectal manometry in patients with fecal incontinence (plus transanal sonography to determine anatomic damage in the subgroups in which the sphincter had been involved) and defecography in those with constipation (plus transit radiography to exclude intestinal colic-associated constipation).

RESULTS

The number of patients classified as having severe incontinence decreased from 8 to 1 (-87.5%), those with moderate incontinence decreased from 8 to 4 (-50%); 20 out of 25 patients presented with mild dysfunction at the end of the rehabilitation program. No difference in response to treatment was found between the two subgroups of patients with fecal incontinence nor among those with constipation. Of those with predominant constipation, none were classified as having severe dysfunction; the number of those with moderate dysfunction decreased from 13 to 7 (-54%).

CONCLUSIONS

The study results show that, when sufficiently motivated, patients with fecal incontinence and constipation following anorectal surgery respond positively to pelvic floor rehabilitation.

[Treatment of anal incontinence]

Diagnosis and treatment of anal incontinence in outpatient care are simple and usually quite feasible for the general practitioner. The main single cause of the incontinence is an age-related weakening of the pelvic floor. The basic care invariably involves moderation of the bowel function by medication and diet as well as strengthening of pelvic floor muscles, which is suitable for the treatment of both anal and urinary incontinence. If basic care does not help, the patient is sent into specialized care. Corrective surgical operations of the sphincter yield varying results. Neurostimulation can be tried for nearly all patients suffering from severe fecal incontinence.

[Assessment of urinary incontinence in the elderly using the InterRAI-AC instrument]

The aim of this study was to identify and evaluate the prevalence of urinary incontinence and risk factors that influenced it among inpatients treated in the departments of internal medicine.

MATERIAL AND METHODS

A total of 151 inpatients were questioned using a standardized geriatric questionnaire (InterRAI-Acute Care). Inpatients aged 65 years and more and who gave written informed consent were enrolled into the study. The mean age of the inpatients was 78+/-0.6 years. There were 58.9% of women and 41.06% of men.

RESULTS

Urinary incontinence was significantly influenced by the age of the inpatients. Inpatients with urinary incontinence were 3 years older on the average as compared to those without urinary continence (P<0.025). Women were more frequently affected than men (74.2% vs. 48.4%). A significant association between urinary and fecal incontinence and memory problems, movement disorders, delirium, dependence in daily activities, falls was established. The odds of having double incontinence were increased by dementia (OR=20.9; 95%, CI 2.3-186) and residual effects of a stroke (OR=3.5; 95%, CI 1.2-9.6). The prevalence of urinary incontinence decreased from 63.6% before hospitalization to 39.7% after hospitalization. According to standard medical documentation, urinary incontinence was diagnosed in 3.3% of cases, while using the interRAI-AC questionnaire, it was documented in 63.6% of cases.

CONCLUSIONS

The prevalence of urinary incontinence increases in the elderly; therefore, it has to be investigated and treated. Memory problems, delirium, dependence in daily activities, movement disorders, and falls are directly related to the risk of urinary, fecal, and double incontinence among elderly inpatients. Double incontinence was significantly influenced by dementia (20.9 times) and residual effects of a stroke (3.5 times). Underdiagnosis of urinary and fecal incontinence in inpatients burdens the possibility of providing aid for elderly patients with this disorder.

[Assessment of anal incontinence in adults]

BACKGROUND

Anal incontinence is involuntary loss of stool and flatus through the anal canal. The condition can be severely debilitating to those affected.

MATERIAL AND METHODS

The article is based on relevant literature and the authors' clinical experience.

RESULTS

The first examination should include an anorectoscopy as part of a broader clinical examination, and the aim should be to find the cause and describe the condition. An assessment in hospital should comprise endoanal ultrasound for imaging and grading of the incontinence severity with a score system.

CONCLUSION

Simple preliminary investigations and eventually more specialized investigations in a specialist clinic give a good impression of the condition, and is the basis for choosing treatment and later evaluation.

[Limited predictive value of diagnostic tests for outcomes following pelvic floor physiotherapy in patients with faecal incontinence]

OBJECTIVE

To develop an efficient diagnostic strategy for patients with faecal incontinence to identify subgroups that may benefit from pelvic floor physiotherapy.

DESIGN

Cohort study.

METHOD

Assessment of consecutive patients with faecal incontinence treated at 15 hospitals in a 24-month period. In addition to medical history and physical examination, a complete diagnostic work-up was performed. All patients were then offered standardised pelvic floor physiotherapy. Treatment outcome was evaluated by change in Vaizey incontinence score 3 months after therapy. Linear regression analysis was used to calculate the predictive value of each diagnostic test and combination of tests with regard to treatment outcomes.

RESULTS

Of the 281 patients included (mean age 59 years), 252 were female. The median Vaizey score was 18 at baseline and 16 after therapy (p < 0.001). The Vaizey score improved in 143/239 patients (60%). The presence of perineal or perianal scarring on physical examination or internal anal sphincter atrophy on endoanal MRI were associated with a negative treatment outcome. A high maximal squeeze pressure by anorectal manometry was associated with a positive treatment outcome. The predictive value of information obtained by medical history and additional tests was limited (R2: 0.23; p = 0.02).

CONCLUSION

Pelvic floor physiotherapy provided a modest improvement in symptoms of faecal incontinence. The predictive value of additional tests in predicting outcomes following pelvic floor physiotherapy was limited. Subgroups of patients could not be identified based on diagnostic test information.

[Faecal incontinence: physiotherapy first before referral for further diagnostics and therapy]

The predictive value of diagnostic tests for faecal incontinence with respect to the outcome of physiotherapy was investigated in a recent study. No obvious predictors were found. This is not surprising. Diagnostic tests are known to exhibit a large overlap with healthy controls. Further, the study was carried out in 15 hospitals, each of which had its own method for performing these tests. Physiotherapy according to a treatment protocol was given by 48 physiotherapists. The Vaizey score was used as the outcome measure and revealed an improvement of 50% or more in 13% of patients. However, some clinical changes important for the patient are missed by this score. The rate of effectiveness for physiotherapy reported in literature is around 70%. This study not only shows that diagnostic tests have little predictive value regarding the outcome of physiotherapy, but, more importantly, that all patients with faecal incontinence should have physiotherapy first. Patients who do not improve should be referred to a specialist for further diagnostics and therapy.

Investigation to predict faecal continence in patients undergoing reversal of a defunctioning stoma (Porridge enema test)

OBJECTIVE

A defunctioning stoma is often performed in cases of major anorectal surgery or sphincter injury. This study aimed to assess the Porridge enema (PE) test as a tool to evaluate function prior to stoma closure.

METHOD

Thirty-eight patients underwent PE test at a median of 12.5 months after stoma formation prior to consideration of stoma closure. Outcome was assessed by immediate leakage after PE test on lying, standing, walking and the ability to hold the enema for 30 min. Patients available for follow-up were divided into two groups: group 1 (n = 20) patients with stoma closure performed and group 2 (n = 10) patients where the stoma remains. Eight patients were excluded from analysis as the stoma had not been reversed for reasons unrelated to continence. The results of other investigations performed in these patients were analysed. Finally, we studied the agreement in the interpretation of the test by two investigators blinded to the patient's group and each other's interpretation and to functional results after the stoma was reversed.

RESULTS

Anorectal physiology testing and imaging assessment of the anal sphincters was not statistically different between the two groups. There was a significant difference in the percentage of patients in each group that had enema leakage in: lying position (P = 0.002), standing position (P = 0.013), walking (P = 0.002) and ability to defer for 30 min (P = 0.005). There was a good correlation in the interpretation of PE test results by two investigators. Among patients whose stoma was closed and who were evaluated functionally, 55% were fully continent.

CONCLUSION

This report suggests that the PE test is a promising tool as part of evaluation of anorectal function prior to stoma reversal.

[Significance of spina bifida occulta in non-retentive fecal incontinence in children]

OBJECTIVE

To explore the pathophysiological significance of spina bifida occulta (SBO) in non-retentive fecal incontinence (NRFI) in children.

METHODS

Twenty-seven children with NRFI diagnosed according to the Rome III criteria, 21 with SBO, aged (7.9 +/- 2.4) years, and 6 without SBO, aged (7.5 +/- 1.9) years, and 226 normal controls, aged (8.4 +/- 2.7) years, underwent plain X-ray photography, neurophysiological study, colonic transit test, electromyography (EMG), and anorectal manometry. The resting vector volume, squeezing vector volume, resting EMG amplitude, and squeezing EMG amplitude, which predominantly reflect internal and external anal sphincter function, were recorded.

RESULTS

The prevalence rate of SBO in the children with NRFI was 78%, significantly higher than that of the normal controls (24%). The resting vector volume, squeezing vector volume, resting EMG amplitude, and squeezing EMG amplitude, of the children with NRFI were all significantly lower than those of the normal controls; however, there were no significant differences in these indexes between the NRFI children with and without SBO. The total colonic transit time of the NRFI children with SBO was (41 +/- 17) h, significantly longer than those of the children without SBO and normal controls (24 +/- 5) h and (29 +/- 8) h, both P < 0.05]. Neurophysiologic test showed that the latency of pudendi-anal reflex of the NRFI children with SBO was (52 +/- 20) ms, significant longer than those of the NRFI children without SBO and normal controls [(29 +/- 9) ms and (23 +/- 7) ms respectively, both P < 0.05].

CONCLUSION

SBO is a major cause of NRFI. Treatment should be focused on recovery of the functions of nervous system.