Does incontinence severity correlate with quality of life? Prospective analysis of 502 consecutive patients

OBJECTIVE

The Fecal Incontinence Severity Index (FISI) is widely used in the assessment of patients with faecal incontinence, but the relationship between FISI and the measurements of quality of life, such as the Fecal Incontinence Quality of Life Scale (FIQL) and the Medical Outcomes Survey (SF-36) has not been evaluated previously. The aim of the present study was to evaluate the relationship between disease severity and quality of life in a large cohort of patients.

METHOD

Five hundred and two consecutive patients (84.4% female, mean age 56 years) were evaluated for faecal incontinence between May 2004 and October 2005. Patients completed FISI, FIQL and SF-36 questionnaires. Pearson's coefficients were determined for the relationships between FISI and subscales of FIQL and SF-36. Quality of life scores were compared between groups of patients with different levels of incontinence severity (mild, moderate, severe) using Student's t-test.

RESULTS

Sixty-eight per cent of patients were incontinent of solid stool, 62% of liquid stool, and 90% of gas or mucus. The average FISI score was 36 (0-61). Moderate correlations were found between FISI and all subscales in FIQL (negative 0.29 to 0.41; P < 0.0001). Weak correlations were found between FISI and the social functioning (-0.21) and mental health (-0.17) scales in SF-36 (P < 0.05). Scores on the FIQL differed significantly between mild, moderate and severe incontinence.

CONCLUSION

FISI was only moderately correlated with a disease-specific quality of life measurement (FIQL). Even though this supports the common assumption that the quality of life in the patients with faecal incontinence worsens with an increase in disease severity, it also stresses the need of measuring both variables to determine the true impact of any treatment.

Pilot study of two new injectable bulking agents for the treatment of faecal incontinence

OBJECTIVE

The use of injectable bulking agents for passive faecal incontinence appears to provide reasonable short-term results. However experience with different agents is limited. We report on the outcome of injections with new bulking agents.

METHOD

Each patient received injections of either Bulkamid (hydrogel cross-linked with polyacrylamide) or Permacol (porcine dermal collagen). Assessment included clinical evaluation, anorectal physiological testing, endoanal ultrasonography and questionnaires including the St Mark's Incontinence Score, one week bowel diary card, the Faecal Incontinence Quality of Life Scale and the Short Form-36 (SF-36) health survey. Follow up was at 6 weeks and 6 months, with a further telephone review at a median of 19 months (range 14-22).

RESULTS

Ten patients (nine female), median age 68 years (range 45-79), were enrolled. St Mark's incontinence score (0 = best, 24 = worst) was 15 (range 11-24) at baseline, 12.5 (range 3-18) at 6 weeks and 14 (range 6-22) at 6 months. A 1-week bowel diary and SF-36 forms also showed temporary improvement but this was not sustained beyond 6 weeks.

CONCLUSION

Bulkamid and Permacol injections did not have a major effect on faecal incontinence.

Awareness of investigations and treatment of faecal incontinence among the general practitioners: a postal questionnaire survey

OBJECTIVE

Faecal incontinence is a distressing condition that can result in significant embarrassment and limitation of routine activities. General practitioners (GP) are the primary carers of such patients. There are recent developments in the surgical treatment options for this under-reported condition. Awareness of these changes is required to make the best use of them. To the best knowledge of the authors, no studies have examined the awareness of investigations and treatment options for faecal incontinence amongst GPs. This is the focus of our study.

METHOD

A confidential questionnaire was posted to GPs in the Yorkshire region. The questionnaire was designed to assess: first, the basic knowledge of GPs with regard to prevalence, investigations and treatment modalities of faecal incontinence and secondly, the patterns of consultations and referrals of patients with faecal incontinence.

RESULTS

One thousand and one hundred questionnaires were posted. Five hundred and four were returned giving a response rate of 48.5% (n = 504). The prevalence assessed by the GPs is similar to that by population based surveys. Only 32% (n = 162) of GPs were aware of at least one investigation. Similarly only 32% of the GP's were aware of at least one form of surgical treatment. The knowledge of UK centres where these facilities are available was limited (60% not aware). Only one quarter of the GPs referred the patients to the surgical specialties. Surprisingly, there was no significant difference in the level of knowledge of investigation and treatments between the GPs who see patients with faecal incontinence more frequently compared with those who see such patients infrequently (P-values 0.298 and 0.432 respectively).

CONCLUSION

The level of awareness of investigation modalities and treatment options for faecal incontinence is limited among GPs. Knowledge of the existence of diagnostic tests and surgical treatment options for faecal incontinence and the centres with these facilities is needed for the best utilization of the technical resources and expertise. Further studies are needed to assess the impact of this lack of knowledge on the quality of patient care. Better communication between referral centres and GPs, combined with continuing medical education programmes, may be useful tools to improve appropriate patient management.

[Gastrointestinal involvement in systemic sclerosis. An underestimated complication]

Systemic sclerosis (SSc) belongs to the family of autoimmune connective tissue diseases and is still a challenge to every practicing physician. The disorder is characterized by progressing fibrosis of the skin and internal organs, abnormal activation of the immune system, and distinct changes in microcirculation. Although it is rare--with a prevalence of about 20:100000--patients need to be cared for in a daily setting. In general thickening of the skin is the first sign of the disease, so dermatologists are most frequently consulted first. Two subtypes exist, limited and diffuse forms. Both entities usually involve internal organs, and therefore interdisciplinary cooperation is mandatory. The increased morbidity and mortality depend predominantly on the grade of involvement of the affected organs. Therefore it is essential to diagnose systemic sclerosis early and to identify and monitor all complications closely. In this respect gastrointestinal involvement is frequently neglected, owing to its primarily non-life-threatening character, resulting in substantially delayed therapy.

Fecal incontinence: a review

Fecal incontinence (FI) is defined as the involuntary passage of fecal material through the anal canal. True incontinence must be differentiated from pseudo incontinence. FI is predominately a disease of the elderly or of institutional patients. Fecal incontinence in the nursing home population has been estimated at 47%. We provide a guide to appropriate clinical evaluation, diagnostic testing, and treatment of FI.

Evaluation of the use of PTQ implants for the treatment of incontinent patients due to internal anal sphincter dysfunction

OBJECTIVE

This study reports the results of injectable silicone PTQ implants for faecal incontinence due to internal anal sphincter (IAS) dysfunction.

METHOD

Twenty patients (12 women) with partial faecal incontinence aged from 55 to 65 years were treated by a PTQ implant. All patients completed the Cleveland Clinic Continence and Quality of Life questionnaire. Endoluminal ultrasound and anorectal physiological testing were performed in each patient. All implants were inserted into the submucosal plane without ultrasound guidance.

RESULTS

Faecal continence was significantly improved up to 1 year. The Wexner continence score fell from a median of 13.05 (range, 5-20) before treatment to 4.5 (range 2-7.7) at 1 month after (P < 0.005). This rose gradually to 6.2 (range, 0-16) at one year (P = 0.02) and 9.4 (range, 1-20) at 2 years (P = 0.127). There were no differences in resting or squeeze pressure before and at 3 months after treatment (P = 0.86 and P = 0.93). Fourteen (70%) patients experienced pruritus ani during the first few weeks after the procedure and one developed infection at the implant site.

CONCLUSION

Silicone implantation is minimally invasive and technically simple. It is effective over 1 year in the treatment of faecal incontinence due to IAS dysfunction.

Development and validation of the pelvic floor inventories Leiden (PelFIs)

AIMS

To evaluate the validity and reliability in Dutch of the Pelvic Floor Inventories Leiden (PelFIs) for men and women, an administered questionnaire, developed to create a condition-specific pelvic floor questionnaire addressing all symptoms of micturition, defecation and sexual dysfunction related to pelvic floor dysfunction.

METHODS

The PelFIs is an 83-item instrument for women and 76-item instrument for men measuring the degree of pelvic floor dysfunction, containing nine different domains. Questions have been selected which, from a clinical point of view, should configure a domain. The PelFIs was administered to healthy volunteers (N = 120), and to patients (N = 100). Reliability of the PelFIs was assessed by internal consistency and test-retest reliability. Construct validity was established comparing healthy volunteers and patients by intercorrelating the domains.

RESULTS

A total of 220 questionnaires were completed; by 147 women and 73 men. Some domains in the men's questionnaire had a low alpha (alpha) although the overall alpha was good. The overall of the domains for men ranged from 0.53 to 0.90. The internal consistency for the total scale of men's questionnaire was 0.84. The overall of the domains in women ranged from 0.60 to 0.85. The internal consistency of the women's questionnaire was 0.88 for the total scale. Intraclass correlation ranged from 0.65 to 0.88. Differences between healthy volunteers and patients were statistically significant for all domains.

CONCLUSION

The PelFIs is a new, practical and conceptually clear questionnaire, which focus on micturition, defecation and/or sexual dysfunction related to pelvic floor dysfunction.

Fecal incontinence: an update on available techniques in diagnosis and treatment

Fecal incontinence remains a major problem with significant social and medical implications. Its causes are diverse and not always apparent. Therefore, diagnostic workup is essential to find the underlying cause and initiate adequate treatment. Treatment options include conservative interventions and surgical procedures. To improve the diagnosis and treatment of patients suffering from fecal incontinence, an update and overview of available techniques can be helpful. This chapter includes indications and complications in conservative and surgical treatment. It also includes flowcharts for everyday practice.

Validation linguistique en français des versions courtes des questionnaires de symptômes (PFDI-20) et de qualité de vie (PFIQ-7) chez les patientes présentant un trouble de la statique pelvienne

INTRODUCTION

The aim of this work was to develop a linguistically validated French version of two short-form questionnaires on symptoms and quality of life in female patients with pelvic floor disorders (PFDI-20, PFIQ-7), originally developed and psychometrically validated in English.

MATERIAL AND METHODS

French versions of the short form Pelvic Floor Disorder Inventory (PFDI-20) and Pelvic Floor Impact Questionnaire (PFIQ-7) were developed after two independent forward translations (English-French), one back translation (French-English), a review by French clinicians and patient testing on a sample of patients with pelvic floor disorders. This linguistic validation process was led in collaboration with Mapi Research Institute and the author of the original English version, Dr Matthew Barber, and sponsored by Coloplast.

RESULTS

These two self-administered questionnaires are completed by patients without a medical presence. They cover urinary, colo-recto-anal and pelvic/vaginal symptoms related to pelvic floor disorders. Psychometric evaluation of the original US English questionnaires found a good correlation between answers provided and clinical symptoms leading the patient to seek medical attention. Their main advantage is their ease of interpretation through the use of a numeric score. Linguistic validation does not consist in translating original questionnaires literally, but rather in developing conceptually equivalent and culturally appropriate versions adapted to the target country. These questionnaires are invaluable instruments to evaluate functional aspects of various forms of pelvic organ prolapse.

CONCLUSION

The French versions of the PFDI-20 and PFIQ-7 are the first linguistically validated instruments available in French to evaluate symptoms and quality of life in patients with pelvic floor disorders.

Contribution of posture to anorectal manometric measurements: are the measurements in left-lateral position physiologic?

PURPOSE

Anorectal manometry is commonly used to investigate fecal incontinence. Traditional practice dictates that measurements are performed with the patient in the left-lateral position however, episodes of fecal incontinence usually occur in the erect position. The influence of erect posture on anorectal manometry has not been studied.

METHODS

We examined the contribution of posture to commonly measured variables during manometry by performing assessment in the left-lateral position and the erect posture. Maximum mean resting pressure, vector volumes, and resting pressure gradient were compared.

RESULTS

Complete data were available for 172 patients. Median age was 55 (interquartile range, 44-65) years. Thirty-seven (22 percent) patients were continent, and 135 (78 percent) were incontinent. Both resting pressure and vector volume increased significantly in the erect position for both continent (P = 0.008 and 0.001, respectively) and incontinent (P = 0.001 for both) patients. A significant negative correlation was seen between severity of incontinence and resting pressure in the erect posture and amount of change in maximum mean resting pressure from left-lateral to erect posture (Spearman coefficients = -0.203, -0.211, and P = 0.013, 0.017, respectively) but not with maximum mean resting pressure in the left-lateral position (Spearman coefficient = -0.119; P = 0.164).

CONCLUSIONS

Our study shows significant increase in measurements of manometric variables in the erect position. The increase may be related to anal cushions, which have a significant role in this position. The measurements in erect posture are better correlated with severity of incontinence and may be a more physiologic method of performing anorectal manometry.

Guidelines for managing faecal incontinence

Mary Wilson reviews the NICE guidelines on the management of faecal incontinence.

How to Try This

Fulmer SPICES is a framework for assessing older adults that focuses on six common "marker conditions": sleep problems, problems with eating and feeding, incontinence, confusion, evidence of falls, and skin breakdown. These conditions provide a snapshot of a patient's overall health and the quality of care. The SPICES assessment, done regularly, can signal the need for more specific assessment and lead to the prevention and treatment of these common conditions. For a free online video demonstrating the use of SPICES, go to http://links.lww.com/A100.

The role of endoluminal imaging in clinical outcome of overlapping anterior anal sphincter repair in patients with fecal incontinence

OBJECTIVE

Anterior sphincter repair has become the operation of choice in patients with fecal incontinence who have defects of the external anal sphincter (EAS), but not all patients benefit from surgery. The aim of this study was to investigate whether endoluminal imaging can identify determinants that play a role in the outcome of sphincter repair.

SUBJECTS AND METHODS

Thirty fecal incontinent patients with an EAS defect were included. The severity of incontinence was evaluated pre- and postoperatively using the Vaizey incontinence score. Patients underwent endoanal MRI and endoanal sonography before and after sphincter repair. We evaluated the association between preoperatively assessed EAS measurements with outcome and postoperatively depicted residual defects, atrophy, tissue at overlap, and sphincter overlap with clinical outcome.

RESULTS

After surgery, the mean Vaizey score in 30 patients (97% females; mean age, 50 years) had improved from 18 to 13 (p < 0.001). MRI showed that baseline measurement of preserved EAS thickness correlated with a better outcome (r = 0.42; p = 0.03). Clinical outcome did not differ between patients with and those without a persistent EAS defect (p = 0.54) or EAS atrophy (p = 0.26) depicted on MRI. Patients with a visible overlap and less than 20% fat tissue had a better outcome than patients with nonvisible, fatty overlap (decrease in Vaizey score, 7 vs 2 points, respectively; p = 0.04). Sonography showed that patients with a persistent EAS defect had a worse outcome than those without an EAS defect (17 vs 10 points, respectively; p = 0.003).

CONCLUSION

Endoanal MRI was useful in determining EAS thickness and structure, and endoanal sonography was effective in depicting residual EAS defects.

Geriatric incontinence--selected questions

Co-existing incontinence (urinary and fecal incontinence), often referred to as double incontinence, is a poorly defined syndrome in older adults. Nevertheless, urinary and fecal incontinence are common problems in the elderly population, particularly affecting individuals in the community and nursing homes. In addition to the inconvenience of the incontinence for the patient and caregiver, it is a marker of poorer health and associated with increased mortality. All patients with fecal and/ or urinary incontinence warrant a focused medical evaluation including comprehensive history and genital examination. Fecal impaction must be excluded by rectal exam and x-ray film of the abdomen. Cognitively impaired patients benefit most from habit training. Several surgical procedures are available and may be helpful in selected older persons with incontinence.

Prospective study of the diagnostic evaluation of faecal incontinence and leakage in male patients

OBJECTIVE

Male faecal incontinence (FI) has received little attention. No consistent pathophysiological abnormality has been identified in those studies that have specifically assessed male patients with FI or faecal leakage (FL). This study was designed to re-examine the different theories relating to the pathophysiology of male incontinence and to assess if manometric and ultrasound assessment yields clinically relevant information that directs patient care.

METHOD

This was a prospective study of all men referred to a Coloproctology clinic with incontinence. The Wexner Incontinence score was used to assess severity of symptoms. Specific investigations included anal manometry, rectal sensation and endo-anal ultrasound (EAUS). Results were compared with a group of 20 normal male controls.

RESULTS

A total of 59 symptomatic male patients were investigated (36 FI, 23 FL). FL and control groups had similar maximum resting (MRP) and maximum squeeze pressure (MSP). The incontinence group had a significantly lower MRP & MSP compared with controls [MRP: FI 58 (42-75.5) vs control 85 (72-104)] (P < 0.0001), [MSP: FI 167 (125-215) vs control 248 (192-302)] (P < 0.0001). There was no significant difference in rectal sensation between the groups and the defecation index was also similar. EAUS detected only one external anal sphincter defect amongst the 23 male patients with FL. One external sphincter defect and three internal sphincter defects were identified amongst the 36 patients with incontinence. Of these five patients with sphincter defects, four had previously undergone anorectal surgery. [Results expressed as median (interquartile range): manometry expressed as mmHg].

CONCLUSION

Male patients presenting with faecal incontinence frequently show impaired sphincter function which may be associated with sphincter defects. In contrast, those presenting predominantly with FL have no morphological or physiological changes that might account for their symptoms. Investigating such patients with anorectal physiology and EAUS is usually unhelpful and can be omitted.

The challenge of obtaining continence in a child with a neurogenic bowel disorder

Fecal incontinence in pediatrics can occur from an array of conditions. A challenging group of pediatric patients are those with a neurogenic bowel disorder who can face a lifelong struggle with attaining and maintaining continence. It is difficult to develop a "cookbook approach" to care, particularly because these children's unique physical needs change as they develop. In addition to addressing physical needs, children's emotional and developmental needs must also be incorporated into the plan of care. This article provides an overview of the common congenital conditions in children with a neurogenic bowel, reviews assessment, and addresses treatment options that should be considered when developing a bowel management program.

Anorectal motor disorders

Anorectal motor disorders such as faecal incontinence, chronic anorectal pain and solitary rectal ulcer syndrome are common in the community. They cause psychological distress, affect quality of life, and pose a significant economic burden. In recent years, many strides have been made in the diagnostic criteria and in the mechanistic understanding of anorectal disorders. The use of innovative manometric, neurophysiological and radiological techniques have shed new light on the underlying pathophysiology. Also, it has been recognised that psychological dysfunction play an important role. However, there is a lack of consensus regarding what is abnormal, regarding the overlap between phenotypes and regarding optimal diagnostic approaches or tests. There has been little advance in drug therapy for these conditions. Although several treatments have been tried and appear promising, controlled trials are either lacking or have provided insignificant evidence. There is a need for improved medical, behavioural and surgical treatments for these conditions.

Recognizing and Treating Pelvic Pain and Pelvic Floor Dysfunction

The reported prevalence rates of pain within the pelvis range from 3.8% to 24% in women aged 15 to 73 years. Despite the significant number of women affected, pelvic floor pain and dysfunction are commonly overlooked in women seeking medical care. Physiatrists are uniquely qualified to manage these patients because of their knowledge of the musculoskeletal and nervous systems and their awareness of the relationships among pain, physiology, and function. When evaluating women who have pelvic pain, practitioners must ask questions about history of urinary or fecal incontinence, dyspareunia, or pelvic pain with certain activities or associated with menses, surgery, or trauma. If left unidentified, pelvic floor dysfunction can deter individuals from normal bowel and bladder function, intimacy, and even engagement in work and social functions. This article introduces pelvic floor anatomy, neurophysiology, and function and provides an overview of pelvic pain and pelvic floor dysfunctions and their recognition and treatment.

Resection rectopexy for external rectal prolapse reduces constipation and anal incontinence

BACKGROUND AND AIMS

The main aim was to examine constipation and anal incontinence in patients before and after resection for external rectal prolapse.

MATERIAL AND METHODS

Twenty patients had ligament preserving suture rectopexy and sigmoid resection (resection rectopexy) for external rectal prolapse by laparoscopic (n = 15) or open (n = 5) technique during 2001-2005. They were prospectively evaluated for constipation and anal incontinence using validated incontinence and KESS-constipation scores.

RESULTS AND CONCLUSIONS

Constipation score was significantly reduced from mean 7.7 (5.4-9.9) to 4.5 (2.5-6.4) after median 4 months (1-19) and to 4.3 (2.2-6.3) after median 17 months (4-51). Six and four patients were constipated preoperatively and 17 months postoperatively, respectively. The four symptoms feeling incomplete evacuation of stool, minutes in lavatory per attempt, use of enemas/digitation and painful evacuation effort were significantly reduced, whilst stool consistency increased. Fourteen patients (70%) had anal incontinence. Corresponding and significant reduction in their scores were from mean 12.5 (9.4-15.5) to 5.1 (2.1-8.1) and to 3.6 (1.3-5.9). Incontinence was improved in 13 and unaltered in one patient(s). Two patients with worse outcome had increased stool consistency and constipation scores. Resection rectopexy for rectal prolapse reduced anal incontinence and constipation.

Empfehlungen zur Anorektalen Manometrie im Erwachsenenalter

This document contains the guidelines of the German Societies of Neurogastroenterology and Motility, Gastroenterology (committee for proctology), Abdominal Surgery (coloproctology working group), and Coloproctology for anorectal manometry in adults. Recommendations are given about technical notes, study preparation (equipment; patient), technique for performing manometry and data analysis, reproducibility, and indications. Minimum standards for anorectal manometry are measurement of resting and squeeze pressure, testing of rectoanal inhibitory reflex, determination of rectal sensation (first perception and urge), and calculation of rectal compliance. Anorectal manometry is indicated in patients with fecal incontinence and constipation in the context of a structured programme.

Postoperative anorectal manometric evaluation of patients with anorectal malformation

BACKGROUND

Fecal incontinence is a common problem after reconstructive surgery for anorectal malformations. The aim of this study was to investigate the effectiveness of clinical scores and anorectal manometry in patients, who have been operated on for anorectal malformations.

METHODS

In total, 18 patients who underwent surgery for anorectal malformation between 1999 and 2004 were investigated for anal continence. For the assessment of the patients' continence, Kelly's clinical scoring, Kiesewetter-Chang scoring, and anorectal manometry were used.

RESULTS

In the intermediate level anorectal malformations, average anal resting pressure was found as 58.16 +/- 8.14 cmH(2)O and in high level anorectal malformations was found as 40.16 +/- 17.4 cmH(2)O. In the continence score, good according to Kelly and Kiesewetter-Chang scoring systems was an average anal resting pressure value of 57.92 +/- 8.57 cmH(2)O and in fair or bad was found as 32 +/- 12.83 cmH(2)O. There were significant differences between the scoring systems anorectal malformation level, and average anal resting pressure values (P < 0.05).

CONCLUSIONS

Anorectal manometric evaluation of the patients in postoperative period with anorectal malformation can give more realistic information about the patient continence status in anorectal malformations.

Faecal incontinence

BACKGROUND

Faecal incontinence is a life style-limiting condition with multiple aetiologies. Surgical cure is not often possible.

METHODS AND RESULTS

A review of the literature was undertaken using Medline, Cochrane database and standard textbooks. Advanced imaging techniques now inform the treatment algorithm and objectively assess success. The long-term outcome of anal surgery is uncertain. Modern approaches favour conservative measures, such as biofeedback, and less invasive surgical procedures. Stoma formation is a definitive option for some patients.

CONCLUSION

Current treatment of faecal incontinence is evolving from a sphincter-focused view to a more holistic one, recognizing the influence of the pelvic floor and psyche in maintaining continence. Modern imaging modalities direct treatment strategies.

[Self reported quality of life among patients referred to a gynaecologic ward with urinary incontinence]

INTRODUCTION

Urinary incontinence (UI) represents a frequent symptom among women of all ages. However, very few women are admitted to a hospital or clinic because of UI. The aim of the paper was to characterize women admitted to hospital because of UI in respect to symptoms and self reported quality of life.

MATERIALS AND METHODS

The study comprised all 174 women admitted to a gynaecologic ward due to lower urinary tract symptoms (LUTS) in the period from 1 November 1999 to 1 August 2001. A total of 142 women (82%) completed validated questionnaires on symptoms and quality of life and were included in this analysis.

RESULTS

The median age was 59 years. The majority (97%) had UI at least once a week. Many patients reported other LUTS--in particular nocturia (87%) and urgency (81%). Two-thirds of the women experienced UI as a major problem. The single most affected factor in terms of quality of life--mental well being--was compromised in two-thirds of the cases. Half of all women were incontinent for flatus, one-third for loose stools and one tenth for normal stools occasionally or more frequently. One out of four women experienced anal incontinence as a major problem.

CONCLUSION

The study shows that the quality of life among women referred to a gynaecologic ward because of LUTS is severely affected. Moreover, the study demonstrates a close association between UI symptoms and symptoms indicating pelvic floor malfunction, such as LUTS and anal incontinence.

Useful parameters helping proctologists to identify patients with defaecatory disorders that may be treated with pelvic floor rehabilitation

BACKGROUND

No studies have specifically reported on the use of a diagnostic tool based on physiatric assessment of constipated or incontinent patients

METHODS

Sixty-seven constipated and 37 incontinent patients were submitted to a standard protocol based on proctologic examination, clinico-physiatric assessment (puborectalis contraction, pubococcygeal test, perineal defence reflex, muscular synergies, postural examination) and instrumental evaluation (anorectal manometry, anal US and dynamic defaecography). Patients were offered pelvic floor rehabilitation (thoraco-abdominoperineal muscle coordination training, biofeedback, electrical stimulation and volumetric rehabilitation).

RESULTS

After rehabilitation treatment, decreases of Wexner constipation score (p=0.0001) and Pescatori incontinence score (p=0.0001) were observed.

CONCLUSION

This diagnostic protocol might improve the selection of patients with defaecatory disorders amenable for rehabilitation treatment.

[Uro- and enterovaginal fistulas]

BACKGROUND

Gynecological fistulas that cause faecal or urinary incontinence, represent a considerable global health problem that usually reflects inadequate help at birth. The problem has a different profile in the more industrialised countries. The aim of the present study was to characterise gynaecological fistulas in a Norwegian setting.

MATERIAL AND METHODS

Data (medical history, type of fistula, treatment and outcome) were recorded from women assessed and treated for uro- and enterogenital fistulas in 1995-2005 at the Woman's clinic Haukeland University Hospital.

RESULTS

Of 82 women, 21 were assessed for uro- and 61 for enterogenital fistula. The verified urogenital fistula (19/21) were mainly caused by surgery (16) and only one came after birth. 17 patients required operative closure. Birth (20) and surgical procedures (17) were the main causes of the 54/61 verified enterogenital fistulas. Cancer (9) and inflammatory bowel disease (14) were important contributing diseases. So far 40 patients have been cured, 38 by surgery. Median time from symptoms to diagnosis seven weeks (range 1 day to 10 years) for urogenital and 15 weeks (range 3 days to 3 years) for enterogenital fistulas.

INTERPRETATION

Obstetrical fistulas represent 1/3 of the vaginal fistulas treated in our department, but in contrast to the developing world, these lesions are mainly enterovaginal. Surgery, cancer and inflammatory bowel diseases comprised the rest of the fistulas. Urovaginal fistulas comprised 1/4 of all fistulas and were almost exclusively caused by surgery. For many patients it took a long time before they received a diagnosis.

Effect of vaginal delivery on endosonographic anal sphincter morphology

OBJECTIVE

To describe the effect of vaginal delivery with no clinically recognized sphincter tear on endosonographic anal sphincter morphology and sphincter pressure and to relate endosonographic results to anal sphincter pressure and anal incontinence score.

STUDY DESIGN

Thirty-two nullipara underwent anal endosonography and anal manometry in the third trimester of pregnancy, 2 weeks and 6 months post-partum. The sphincter defect scores (1-16) and the thickness and length of the sphincters were measured by endosonography, and sphincter pressures and manometric sphincter lengths were determined. The Wexner incontinence score (1-20) was used to classify anal incontinence 6 months post-partum.

RESULTS

Five (16%) women had small endosonographic anal sphincter defects (score 3-4) before delivery. Eight women (25%; confidence interval 11-43%) had new defects detected post-partum, five small, one moderate (score 7), and two large (score 10-11). Six (75%) of eight women with new defects post-partum had undergone episiotomy versus five (21%) of 24 women with no new defects (p = 0.02). Six months after delivery 16 (50%) women reported anal incontinence, and there was a positive correlation between the endosonographic defect score 6 months post-partum and the Wexner incontinence score. The sphincter was significantly longer during pregnancy than 6 months post-partum.

CONCLUSION

New sphincter defects may arise after vaginal delivery without any clinically recognizable sphincter tear. There is a positive correlation between the endosonographic defect score 6 months post-partum and the Wexner incontinence score.

Surgical complications in relation to functional outcomes after ileoanal anastomosis in pediatric patients with ulcerative colitis

BACKGROUND

Significant surgical complications are common in patients with ulcerative colitis who undergo proctocolectomy. We assessed the effects of these complications on the functional outcomes of such patients.

MATERIALS AND METHODS

The medical records of 47 consecutive patients who underwent ileoanal anastomosis (IAA; J-pouch IAA, n = 37; straight IAA [SIAA], n = 10) for ulcerative colitis between 1985 and 2004 at a median age of 13.7 years (range, 5.5-19.3 years) were reviewed. Anastomotic leakage and stenosis, fistula, intestinal obstruction (IO), wound complications, pouchitis/enterocolitis (no/once/recurrent), permanent ileostomy, and ultimate diagnosis of Crohn's disease were recorded and correlated with the functional outcome measures of stooling frequency (6 months, 2 years, present), present incidence of soiling, and continence score (range, 0-12).

RESULTS

The median postoperative follow-up period was 10 years (range, 1-21 years). Twenty-six (55%) of the 47 patients had surgical complications (J-pouch IAA, 21/37 [57%]; SIAA, 5/10 [50%]; P = nonsignificant). These complications specifically included stenosis of IAA in 4 (9%) patients (SIAA 2), pelvic abscess/sepsis in 4 (9%) patients, late fistula in 4 (9%) patients (SIAA 1), early IO in 8 (23%) patients (SIAA 1), late IO in 14 (27%) patients (SIAA 3), J-pouch prolapse in 1 patient, and wound complications in 7 (15%) patients (SIAA 1). Twenty-three (49%) patients had pouchitis, which recurred in 13 (28%). Ileoanal anastomosis stenosis, IO, J-pouch prolapse, wound complications, and pouchitis did not worsen functional outcomes. In 4 patients with pelvic sepsis, early stooling frequency and the continence score were lower than those in the rest of the patients (P < .05). Crohn's disease was ultimately diagnosed in 3 (6%) patients (SIAA 1), 2 of whom (SIAA 1) had permanent ileostomy formation.

CONCLUSIONS

Significant surgical complications are common after IAA. Complications do not generally worsen functional outcomes, except in those patients with septic complications or the ultimate diagnosis of Crohn's disease.

Laparoscopic rectopexy

Abdominal rectopexy has been advocated as the treatment of choice for complete rectal prolapse. Recurrence rates are low raging from 0-12% and fecal continence has been documented to improve in 3-75% of patients. As most patients are elderly and not always fit enough to undergo abdominal procedure, various perineal approaches have been advocated. Depending on the type and extent of the operation, these procedures have a recurrence of up to 38%. Laparoscopic rectopexy represents the latest development in the evolution of surgical treatment of rectal prolapse. This technique aims to combine the good functional outcome of the open abdominal procedure with the low postoperative morbidity of minimal invasive surgery. We present a laparoscopic rectopexy on 72-year-old lady with a 10-year history of fecal incontinence and mucosal rectal prolapse. Electronic supplementary material is available for this article at http://dx.doi.org/10.1007/s00464-006-0136-y.

Questionnaires to Assess Urinary and Anal Incontinence: Review and Recommendations

PURPOSE

We reviewed and provide recommendations about the most scientifically robust and appropriate questionnaires for evaluating symptoms and the quality of life impact of urinary and/or anal incontinence, and vaginal and pelvic floor problems. We also investigated the use of these questionnaires in randomized, controlled trials of treatment strategies.

MATERIALS AND METHODS

The Symptom and Quality of Life Committee of the International Consultation on Incontinence performed a systematic review of questionnaires related to urinary and anal incontinence, and vaginal and pelvic floor problems, searching MEDLINE, The Cochrane Library and other electronic databases between 2001 and 2004.

RESULTS

A total of 23 robust and relevant questionnaires could be recommended in clinical practice and research. The development of questionnaires to assess anal incontinence, and pelvic floor and vaginal problems has been limited with some promising measures but with none achieving the highest level of rigor. From 2001 to 2004 there were 150 published randomized trials of treatments for incontinence. Increasingly trials of incontinence are using recommended measures (38% of those for urinary incontinence and 22% of those for anal incontinence used the highest quality questionnaires in 2001 to 2004) but none of vaginal and pelvic floor problems used recommended questionnaires.

CONCLUSIONS

With increasing acknowledgment of the value of patient based assessment much attention has been given to the development of questionnaires to assess symptoms and quality of life. Sufficient measures are now available for urinary incontinence, and researchers and clinicians are encouraged to use the 18 achieving the highest level of rigor and their validated translations. In contrast, the development of questionnaires for anal incontinence and pelvic/vaginal problems is in its infancy and further study in this area is needed. Randomized trials of treatments for incontinence should use only questionnaires achieving the highest level of scientific rigor.

Functional nonretentive fecal incontinence in children

Fecal incontinence, the loss of feces in the underwear after age 4 years, is a frustrating phenomenon for children and their parents. It is difficult to treat, presenting as a single symptom without any organic cause or signs of constipation. This review addresses the definition of functional nonretentive fecal incontinence and provides an overview of its epidemiology, pathophysiology, clinical features, diagnostic work-up and prognosis.

Fecal Incontinence: a woman's view

Fecal incontinence (FI) has a prevalence of 2-7% in the general community and increases substantially in hospitalized patients and nursing home residents. Incontinent patients often isolate themselves from society for fear of having an incontinent episode in public. Few of these patients ever discuss this ailment with their doctor, despite a significant increase in depression and anxiety. Women have gender-specific medical and surgical conditions that predispose them to FI such as pregnancy, scleroderma, MS, IBS, childbirth, and pelvic surgeries. This article will address multiple facets of FI, but will focus specifically on issues related to women.

Should we actively screen for urinary and anal incontinence in the general gynaecology outpatients setting?--A prospective observational study

The Department of Health in the UK recommends as good practice in continence services that opportunistic screening for urinary and anal incontinence is carried out by all healthcare professionals. The aim of this study was to record the prevalence of urinary and anal incontinence in a general gynaecology clinic. In addition, to ascertain the proportion of women with incontinence who wish further help and assess the current opportunistic screening for incontinence. Overall, the prevalence of urinary incontinence is 26.8% and the prevalence of mixed (urinary and anal) incontinence is 8.4% of women attending a general gynaecology clinic. The prevalence of both types of incontinence increases with the age of the women. Although a significant proportion wished to receive help, 61.6% of women with urinary incontinence were not specifically asked about urinary incontinence and 66.6% of women with anal or mixed incontinence were not specifically asked about anal incontinence. Our current screening for incontinence is unsatisfactory.

Electromyography of pelvic floor muscles

Pelvic floor muscles (PFM) are intimately involved in function of lower urinary tract, the anorectum and sexual functions, therefore their neural control transcends the primarily important somatic innervation of striated muscle, as they are directly involved in "visceral activity". Neural control of pelvic organs is affected by a unique co-ordination of somatic and autonomic motor nervous systems. Visceral and somatic sensory fibres supply sensory information from pelvic organs; their input influences through central integrative mechanisms also pelvic floor muscle activity. Anatomically, somatic afferent and efferent nerves of the sacral cord segments, reflexly integrated at the spinal cord and brainstem level, conduct neural control of PFM. The inputs from several higher centres influence the complex reflex control and are decisive for voluntary control, and for socially adapted behaviour related to excretory functions.

MRI in evaluating atrophy of the external anal sphincter in patients with fecal incontinence

OBJECTIVE

External anal sphincter atrophy seen at endoanal MRI may predict poor outcome of surgical anal sphincter repair for an external anal sphincter defect. The purposes of this study were to compare external phased-array MRI to endoanal MRI for depicting external anal sphincter atrophy in patients with fecal incontinence and to evaluate observer reproducibility in detecting external anal sphincter atrophy with these techniques.

SUBJECTS AND METHODS

Thirty patients with fecal incontinence (23 women, seven men; mean age, 58.7 years; age range, 37-78 years) underwent both endoanal and external phased-array MRI. Images were evaluated for external anal sphincter atrophy by three radiologists. Measures of differences and agreement between both MRI techniques and of interobserver and intraobserver agreement of both techniques were calculated.

RESULTS

The MRI techniques did not significantly differ in their ability to depict external anal sphincter atrophy (p = 0.63) with good agreement (kappa = 0.72). Interobserver agreement was moderate (kappa = 0.53-0.56) for endoanal MRI and moderate to good (kappa = 0.55-0.8) for external phased-array MRI. Intraobserver agreement was moderate to very good (kappa = 0.57-0.86) for endoanal MRI and fair to very good (kappa = 0.31-0.86) for external phased-array MRI.

CONCLUSION

External phased-array MRI is comparable to endoanal MRI in depicting external anal sphincter atrophy and, thereby, in selecting patients for anal sphincter repair. Because results among interpreters varied considerably depending on the experience level, both techniques can be recommended in the diagnostic workup of fecal incontinence only if sufficient experience is available.

[Current concepts in the pathophysiology, diagnosis and treatment of fecal incontinence]

Fecal incontinence (FI), defined as the recurrent uncontrolled passage of fecal material due to the inability to control bowel discharge is a common and devastating condition. According to previous studies, at least 1 in 10 adult women have FI. This disorder poses a significant economic burden and has a negative impact on patient's lifestyle, leads to a loss of self-confidence, social isolation and a diminished quality of life. Three subgroups of FI are recognized: a) passive incontinence: the involuntary discharge of stool or gas without awareness; b) urge incontinence: the discharge of fecal matter in spite of active attempts to retain bowel contents, and c) fecal seepage: the involuntary leakage of small volumes of stool after normal evacuation. Disruption of the normal structure or function of the anorectal unit leads to FI and is often due to multiple mechanisms. A detailed history and examination including digital rectal examination facilitates diagnosis. Anorectal physiological tests provide useful information regarding functional abnormalities and anal endosonography regarding sphincter defects. These tests provide insights regarding pathophysiology and can guide further management. Behavioral therapy is successful in most patients and should be offered first. Surgical treatment should be considered in cases who fail medical treatment or with sphincter defects. Several experimental approaches, including bulking of the anal sphincter, sacral nerve stimulation and the delivery of radiofrequency energy to the anal canal are under investigation.

Management of bowel dysfunction in people with multiple sclerosis

Bowel dysfunction is a common problem for people with MS. It impacts upon both physical disability and psychosocial wellbeing. This article reviews the limited evidence underpinning best practice. The evidence highlights the importance of a thorough bowel assessment and adequate fluid and fibre intake together with the benefits of pelvic floor exercises. Biofeedback therapy, aerobic exercise and anal plugs are helpful for some people with MS. The use of pharmacological interventions needs to be considered with care.

[Anal incontinence caused by an obstetric trauma. Experience with the technique of overlapping sphincteroplasty]

INTRODUCTION

Anal incontinence (IA) could be of idiopathic, congenital, neurological origin, or secondary to trauma. Obstetric trauma is the most common cause of the traumatic anal incontinence.

OBJECTIVE

To analyze results of a group of patients with anal incontinence secondary to obstetric trauma, with overlapping sphincteroplasty.

PATIENTS AND METHODS

All patients with anal incontinence secondary to obstetric trauma without neurological damage, between January 2002 to January 2006 were studied; all of them underwent overlapping sphincteroplasty. We evaluated improvement in incontinence score according Jorge and Wexner incontinence scale, pre and postoperatively as well as morbi-mortality rates.

RESULTS

16 patients, most of them with total anal incontinence, with preoperative values between 16 to 20 points at the Jorge and Wexner scale; 14 patients (87.5%) referred improvement in their values with 4 to 0 points postoperatively, two patients did not refer significant improvement, both of them with defects in both sphincters and loss of the 50% of the entire sphincteric complex. They were sent to bio-feedback therapy. There was not mortality. Seven patients (43.7%) had skin dehiscence.

CONCLUSIONS

Overlapping sphincteroplasty is an accurately technique for repair obstetric trauma injuries of the anal sphincter, with a success rate of 70 to 80%, and a low morbidity rate.

MR imaging of the pelvic floor

Pelvic floor disorders are a common clinical problem. Clinical evaluation frequently underestimates the extent of the disease. Fluoroscopic colpocystodefecography (CCD) is an established tool for diagnosing disorders of the rectum and recto- anal junction. It is however less performant when it comes to evaluate the complex pelvic floor mechanism in all its aspects. MR defecography allows to evaluate all the compartments of the pelvis without being invasive. This article describes the clinical setting, the MR technique and provides guidelines for interpretation of a MR defecography study.