Incidence of fecal and urinary incontinence following radical perineal and retropubic prostatectomy in a national population

PURPOSE

Since 1991 we have performed more than 300 anatomical radical perineal prostatectomies at Brooke Army and Wilford Hall Medical Centers, and were initially aware of 8 patients who presented with unsolicited postoperative fecal incontinence. We determined the incidence of fecal and urinary incontinence following radical prostatectomy, defined parameters to identify patients at risk for fecal complaints following radical prostatectomy, and estimated the impact of fecal incontinence on lifestyle and activities.

MATERIALS AND METHODS

Initially a validated 26-question telephone survey was used to evaluate 227 patients who had previously undergone radical prostatectomy at 1 of our 2 institutions. Based on results of the telephone survey a national survey was mailed to 1,200 radical prostatectomy patients randomly selected from a nationwide database of Department of Defense health care system beneficiaries. All patients had undergone radical perineal or retropubic prostatectomy at least 12 months before being contacted for the survey.

RESULTS

Responses to the telephone survey from 227 patients revealed that fecal incontinence was a problem after radical retropubic (5%) and perineal (18%) prostatectomy and less than 50% of those with fecal incontinence had told the physician. Our mail survey (response rate 80% and 78% usable for analysis, 784 radical perineal and 123 perineal) strongly indicated that fecal incontinence after radical prostatectomy is a problem nationwide. Frequency of fecal incontinence (daily, weekly, monthly or less than monthly occurrences) was significantly higher among radical perineal (3, 9, 3 and 16%) compared to retropubic prostatectomy (2, 5, 3, and 8%) patients (p=0.002). Fecal incontinence had a significant negative effect on patient social or entertainment activities (p=0.029), and travel and vacation plans (p=0.043). Radical perineal compared to retropubic prostatectomy patients were more likely to wear a pad for stool leakage (p=0.013), experienced more accidents (p=0.001), had larger amounts of stool leakage (p=0.002) and had less formed stools (p=0.001). Of radical perineal prostatectomy patients only 14% and of retropubic only 7% with fecal incontinence had ever told a health care provider about it, even when the incontinence was severe. Responses to our survey concerning urinary incontinence showed that radical perineal prostatectomy patients had a lower rate of urinary incontinence immediately after prostatectomy compared to retropubic (79 versus 85%, p=0.043). A higher proportion of perineal patients reported that all urinary leakage had ceased, that is full continence had returned (perineal 70%, retropubic 53%, p=0.001). A smaller proportion of perineal patients found it necessary to wear a pad to protect from urinary incontinence (perineal 39%, retropubic 56%, p=0.004).

CONCLUSIONS

Fecal incontinence following radical prostatectomy occurs more frequently than previously recognized. In general fecal incontinence among radical perineal and retropubic prostatectomy patients surpasses the expected incidence rate of 4% for this age group (60 to 70 years) but incidence is significantly higher for radical perineal prostatectomy patients. However, radical perineal prostatectomy patients have a significantly lower incidence of urinary incontinence than those treated with retropubic prostatectomy. Surgeons who perform radical retropubic and perineal prostatectomy should be aware of the possibility of fecal and/or urinary incontinence and associated symptoms.

Parenting children with anorectal malformations: implications and experiences

Parents play a crucial role in the life of a child suffering from an anorectal malformation (ARM), since their guidance contributes to the degree to which the child learns to cope with his or her disability. We investigated whether they experience stress in parenting such a child and also attempted to identify somatic or behavioral characteristics in the child that influence the stress of parenting. The parents of 109 children (69 males, 40 females; median age 5.9 years, range 1-18 years) with an ARM (58 low, 10 intermediate, 41 high) were studied. The Nijmegen Questionnaire on Child-rearing Situations (NQCS) was used to investigate the existing parenting situation. Behavioral characteristics of the children were studied by means of the Child Behaviour Checklist (CBCL) and the Teacher Report Form (TRF). In a semi-structured interview, we investigated how parents experienced the implications of the disability in everyday life with their child. Our study showed that as far as the perception of parenting stress is concerned, parents of children with an ARM do not differ from those with healthy primary-school children. Within the group of parents with ARM-afflicted children, the parents of older, incontinent children experienced relatively more stress, especially when the child concerned was male. With regard to the children's behavior, the parents and teachers under investigation did not report a higher than normal incidence of deviant behavior. However, when individual parents observed difficult behavior in their child, they found it harder to deal with than the incontinence for feces. Regarding the implications of the disorder for their everyday lives, parents were concerned and indicated a need for specific counselling. We conclude that having a child with a somatic affliction, in this case an ARM, does not automatically imply that the parents experience child-rearing problems. However, certain groups of parents are more at risk, i.e., parents with older, incontinent sons and parents with children exhibiting behavioral problems. In addition, our study shows that parents do have difficulties in coping with the implications of the disorder and express a need for support. We feel that patient care can be improved if aid is tailored to these specific problems.

The association between chronic diseases and depressive symptomatology in older Mexican Americans

BACKGROUND

Among the elderly population, the risk for psychological distress increases with the number of chronic diseases and accompanying functional disability. The prevalence of chronic medical conditions and functional disability varies substantially across ethnocultural groups, however. Using data from the Hispanic EPESE, we previously reported that among older Mexican Americans, the total number of chronic medical conditions and the presence of functional impairment are strong predictors of depressive symptoms.

METHODS

Using multiple regression, we examined the association between specific chronic diseases, individual functional disabilities, and depressive symptoms in this group of ethnic elders.

RESULTS

Multiple regression models indicated that diabetes (OR = 1.25, 95% CI = 1.03-1.56), arthritis (OR = 1.42, 95% CI = 1.17-1.72), urinary incontinence (OR = 1.94, 95% CI = 1.46-2.59), bowel incontinence (OR = 2.28, 95% CI = 1.15-4.55), kidney disease (OR = 3.11, 95% CI = 1.13-8.58), and ulcers (OR = 2.56, 95% CI = 1.23-5.29) were predictive of high levels of depressive symptoms. Hip fracture, although recognized as having a substantial impact on functional status, was not found to be associated with depressive symptoms. History of stroke was not significantly associated with depressive symptoms in bivariate or multivariate analyses, but history of stroke with residual speech problems was predictive (OR = 2.16, 95% CI = 1.01-4.79). Among specific activities of daily living, only impaired ability to walk across a room (OR = 1.65, 95% CI = 1.04-2.73) or to bathe oneself (OR = 1.87, 95% CI = 1.12-3.12) proved to be predictive in multivariate analyses.

CONCLUSIONS

This constellation of chronic medical conditions and functional disabilities is very different from those reported to be associated with depressive symptoms in older non-Hispanic White and African Americans, and appears to comprise those conditions most associated with substantial physical impairment, pain, and discomfort.

Effects of anal invasive treatment and incontinence on mental health and psychosocial functioning of adolescents with Hirschsprung's disease and low anorectal anomalies

BACKGROUND/PURPOSE

Recent studies of adolescents with Hirschsprung's disease (HD) and low anorectal anomalies (LARA) showed persistent impairment of fecal control in both groups, but very different mental and psychosocial outcome.

METHODS

To explore possible reasons for these differences, 19 adolescents with HD (aged 10 to 20 years; median, 16) operated on by the Duhamel technique were compared with 17 adolescents with LARA (aged 12 to 20 years; median, 15). The 36 adolescents were assessed for treatment procedures, bowel function, and mental and psychosocial outcome by data collected from medical records, physical examination, semistructured interview, and standardized questionnaires. The parents of 30 adolescents were also interviewed and completed questionnaires.

RESULTS

Duration of anal invasive treatment procedure and current bowel function were associated with mental and psychosocial outcome. The treatment variable, duration of anal dilation, was the most significant predictor of the adolescents's mental health (R2 = .41, P < .01), whereas chronic family difficulties and parental warmth together with the current bowel function variables, fecal and flatus continence function, best explained the variance in psychosocial outcome (R2 = .77, P < .0001). Thus, the differences in treatment procedures and continence function between the HD and LARA groups may partially explain differences in mental and psychosocial outcome.

CONCLUSIONS

These findings suggest that anal dilatation and continence dysfunction may have negative impact on mental health and psychosocial functioning. Indications for and ways of performing the procedure of dilation, and the treatment of persistent incontinence problems, are questioned.

[Functional outcome and quality of life after coloanal or colonic pouch-anal anastomosis--a prosepctive randomized study]

Functional variables after coloanal anastomosis or anastomosis with J pouch were investigated in 40 patients in a prospective randomized study. Continence for liquids and gas control were superior after J pouch anastomosis compared with coloanal reconstruction. The neorectal capacity was higher after J pouch anastomosis. The perception threshold for stool filling was higher in patients with J pouch resembling those values observed preoperatively. Quality of life was improved in subjects with with J pouch, although differences did not reach a significant level.

Conceptualization and treatment of bowel obsessions: two case reports

Bowel obsessions have long been recognized in clinical settings, usually presenting as an overwhelming fear of losing bowel control in public. Conceptual issues with regard to this disorder have hampered treatment efforts. For example, disagreement exists as to its proper classification within the spectrum of anxiety disorders: it has been conceptualized both as a variant of obsessive-compulsive disorder and as a symptom of social phobia, panic disorder, and agoraphobia. In addition, the comorbidity of bowel obsessions and functional bowel disorders such as irritable bowel syndrome is not understood. While reports of pharmacological intervention exist, little has been written about psychological treatment techniques. This paper uses two cases studies of successful behavioral treatment of bowel obsessions as illustrations to address the above issues.

Bowel function, mental health, and psychosocial function in adolescents with Hirschsprung's disease

Congenital intestinal malformations are uncommon and may pose lasting somatic difficulties. Patients with anorectal anomalies have a high frequency of persistent faecal dysfunction and psychosocial problems. This study examined whether adolescents with Hirschsprung's disease have more psychosocial problems than their healthy peers. Nineteen adolescents (mean age 15.7 years) with Hirschsprung's disease were assessed for bowel function, anorectal physiology, mental health, and psychosocial functioning by physical examinations, semistructured interview, and standardised questionnaires. The adolescents were compared with controls. The parents of 13 adolescents with Hirschsprung's disease were interviewed and completed questionnaires. Thirty two per cent of the adolescents with Hirschsprung's disease had significant impairment of continence, but no more psychopathology (16%) nor psychosocial dysfunction as a group than their healthy peers. Faecal incontinence was associated with poorer psychosocial functioning and parental criticism. The fact that a significant number of patients with Hirschsprung's disease have incontinence into adulthood indicates the need for parental counselling, encouraging realistic expectations about continence.

Urinary and fecal incontinence in a community-residing older population in Japan

OBJECTIVE

To estimate the prevalence and risk factors of urinary and fecal incontinence among a community-residing older population in Japan.

DESIGN

Population-based cross-sectional study.

SUBJECTS

A randomly selected sample of 1473 people aged 65 years and older living in the City of Settsu, Osaka, in 1992.

MEASURES

Data collected via in-home visits were used to estimate the prevalence of urinary and fecal incontinence and to provide information regarding potential risk factors of urinary and fecal incontinence.

RESULTS

Data were obtained from 1405 older adults, a response rate of 95.4%. The prevalence of any degree of urinary incontinence was 98/1000 in both sexes, and 87/ 1000 men and 66/1000 women admitted to some degree of fecal incontinence. Daily, 34/1000 and 20/1000 of the population were incontinent of urine and feces, respectively. There was an increasing prevalence of urinary and fecal incontinence with age in both sexes, but the expected greater prevalence in women was not found. By univariate analyses, age older than 75 years, poor general health as measured by Activities of Daily Living, stroke, dementia, no participation in social activities, and lack of life worth living (Ikigai) were associated significantly with both urinary and fecal incontinence. In the multivariate analyses using logistic regression, age older than 75 years, poor general health, and stroke were independent risk factors for any type of incontinence. Diabetes was an independent risk factor for isolated fecal incontinence, and dementia and no participation in social activities were independent risk factors for double incontinence.

CONCLUSIONS

Incontinence of urine and feces is a prevalent condition among very old people living in the community in Japan and is associated highly with health and psychosocial conditions.

Biofeedback therapy for excessive stool frequency and incontinence following anterior resection or total colectomy

PURPOSE

Excessive stool frequency and incontinence after anterior resection (AR) or total colectomy (TC) can be refractory to expectancy and antidiarrheal agents. We prospectively assessed efficacy of anorectal biofeedback therapy (BF) in this clinical situation.

METHODS

Thirteen patients (10 men and 3 women; mean age, 62.1 (standard error of the mean (SEM), 4.6) years) had more than six bowel movements per day and/or episodes of incontinence, which did not abate after antidiarrheal agents were given for at least six (mean, 27.9 (SEM, 6.3)) months after surgery. All underwent four sessions of outpatient BF. Assessment was by continence questionnaire and anorectal physiology tests, which were administered before and after BF.

RESULTS

In seven AR patients, daily stool frequency was decreased (8.7 (SEM, 2.1) before and 4.6 (SEM, 1.2) after, P < 0.05), and daily incontinence episodes were reduced (2.7 (SEM, 0.9) before and 0.4 (SEM, 0.2) after, P < 0.05) after BF. Six TC patients also had decreased daily stool frequency (6.2 (SEM, 2.1) before, 3.3 (SEM, 1.6) after; P < 0.05) and incontinence episodes (2.4 (SEM, 0.9) before, 0.5 (SEM, 1) after; P < 0.05) after BF. There were no significant changes in anorectal physiology parameters after BF. At a mean follow-up of 10.6 (SEM, 2.5) months after BF, there were no regressions or complications.

CONCLUSIONS

BF is a safe and effective option for refractory excessive stool frequency and/or incontinence following AR or TC.

Functional anorectal disorders

The functional anorectal disorders-functional fecal incontinence, pelvic floor dyssynergia-type constipation, levator ani syndrome, and proctalgia fugax-are common but poorly understood gastrointestinal complaints. Fecal incontinence may occur in constipated patients when a fecal impaction of the rectum reflexly inhibits the internal anal sphincter and allows leakage of soft stool, or it may occur in diarrhea. Constipation-related incontinence can be treated with habit training (use of a routine time to defecate backed up by laxatives) or biofeedback to teach relaxation of the pelvic floor, but diarrhea-related fecal incontinence usually requires antidiarrheal medications. Pelvic floor dyssynergia occurs when the pelvic floor muscles paradoxically contract instead of relaxing when the patient strains to defecate. Biofeedback to teach relaxation of these muscles is effective in two thirds of patients. Levator ani syndrome involves chronic, and proctalgia fugax involves fleeting rectal pain. The cause of these painful conditions is unknown, and no treatment of proven efficacy is available.

Somatic function, mental health, and psychosocial adjustment of adolescents with anorectal anomalies

Thirty-three adolescents (aged 12 to 20 years; median, 15) with a corrected low (n = 17) or high (n = 16) anorectal anomaly were assessed using anorectal physiological examination, semistructured interviews [Child Assessment Schedule [CAS]), and questionnaires (Child Behavior Checklist [CBCL], Youth Self-Report [YSR]). Seven patients, all of whom had low malformations, were totally continent. Twenty-three (70%) had persistent dysfunction with staining (n = 12) or intermittent/constant soiling (n = 11). Twenty-four (73%) had flatus incontinence. Fecal incontinence correlated negatively with anal canal resting pressure (r = - .58, P = <.001) and squeeze pressure (r = -.54, P < .01). Three adolescents had a permanent colostomy. Nineteen patients (58%) met the criteria for a psychiatric diagnosis, and impairment of psychosocial function was found in 24 (73%). The degree of psychosocial impairment correlated significantly with fecal incontinence (F = -.37, P < .05) and flatus incontinence (r = -.49, P < .01). Continence of flatus correlated significantly with mental health symptom scores (YSR: r = .52, P < .01; CAS:r = .53, P < .01). The findings indicated that, in addition to soiling, staining as well as fear of flatus are associated with psychiatric and psychosocial dysfunction among patients with anorectal malformations. Optimal treatment of patients with low and high anorectal anomalies requires somatic and psychological care and follow-up into adulthood.

Coping strategies of children with faecal incontinence

As part of a study concerning the psychosocial adjustment of 160 children treated for anorectal anomalies, the authors investigated the ways in which the children coped with faecal incontinence (FIC). At the time of assessment, the children were 6 to 18 years of age. Portions of the in-depth interviews with the children and their parents covered questions about methods of managing and coping with FIC at home, socially, and at school. In addition, information was obtained about child and family characteristics that have been shown to contribute to the ability to adapt to chronic health problems. The ways in which the children dealt with their problems could be grouped into three distinct phases and were different for boys and girls. In phase 1, around 6 to 7 years of age, boys were largely unaware of the unsocial nature of their condition; the girls were sensitive and withdrawn. In phase 2, between 8 and 11 years of age, boys used overt denial, girls used secretiveness. Phase 3, from around 12 years into adolescence, for both sexes was marked by continued covert denial and eventual acceptance of their disability. The coping strategies reflected a complex interrelationship between characteristics of the child, the family, the social environment, and the unsocial and embarrassing nature of FIC. The findings showed that coping with FIC has potentially severely disruptive implications for the overall development of the child.

Continence management

The elderly, critically ill patient is particularly prone to transient and established fecal or urinary incontinence. With proper management, these devastating problems can be managed, alleviated, or prevented promptly. Care of incontinence is not simply a hygienic consideration. Elderly persons who experience loss of bladder or bowel control frequently are depressed, isolated, and fearful of discovery. Left untreated, these individuals are prone to mental and social deterioration that may lead to social isolation or institutionalization. With adequate awareness and prompt management, however, the critical care nurse can prevent transient incontinence from becoming an established pattern, and he or she can serve as a resource for the elderly patient who seeks care and understanding for this significant condition.

Faecal incontinence with transitory absence of anal contraction in two sexually or physically abused women

OBJECTIVE

To report two cases of faecal incontinence caused by transitory absence of anal voluntary contraction without anal anomalies.

PATIENTS

Two women referred to our gastroenterology department with faecal incontinence. One patient had been sexually abused by her father; the other had been physically abused by her husband.

RESULTS

Clinical and manometric anal contraction was absent despite normal anal endosonography and normal electrophysiological perineal study. Anal contraction was completely normalized after biofeedback, and the patients recovered from the faecal incontinence.

CONCLUSION

Transitory absence of anal contraction is very uncommon as the origin of faecal incontinence. It was observed in two abused women.

Can manometric parameters predict response to biofeedback therapy in fecal incontinence?

PURPOSE

Biofeedback therapy may improve fecal control in up to 50 percent to 92 percent of patients with fecal incontinence. Identification of favorable manometric parameters before biofeedback therapy may help in selection of patients suitable for such therapy.

METHODS

Twenty-eight patients with fecal incontinence (idiopathic, 11; iatrogenic trauma, 8; obstetric trauma, 9) who underwent biofeedback therapy were studied to determine whether manometric parameters could predict the result of therapy. Biofeedback was given using a computer software program designed to strengthen the external anal sphincter with auditory and visual feedback.

RESULTS

Thirteen patients (46.4 percent) achieved excellent results; eight patients (28.6 percent) had good results, but seven patients (24.5 percent) failed to improve after biofeedback therapy. Resting or squeeze anal canal pressure, pressure volume, sphincter length, sphincter fatigue rate, and cross-sectional asymmetry of the entire sphincter before biofeedback failed to reveal any statistically significant differences between responders and nonresponders. However, the cross-sectional asymmetry of the high-pressure zone within the sphincter at rest was greater in nonresponders than in responders (not improved, 25.8 percent; good result, 20.2 percent; excellent result, 15.4 percent; P < 0.07). This difference was even greater on squeeze (not improved, 21 percent; good result, 17.6 percent; excellent result, 13.2 percent; P < 0.04). The number of biofeedback sessions, response on bearing down, and quality of rectoanal excitatory reflex were not reliable indicators of outcome. No statistical difference was found in mean resting and squeeze pressures after biofeedback between responders and non-responders.

CONCLUSIONS

Except for increased cross-sectional asymmetry in the high-pressure zone, which may be a forerunner of adverse outcome, manometric parameters before biofeedback do not predict response to biofeedback therapy. Improvement in continence may be independent of resting and squeeze pressures achieved after biofeedback therapy.

Psychosocial adjustment of children treated for anorectal anomalies

The psychosocial adjustment of 160 children with anorectal malformations was assessed at 6 to 17 years of age in relation to levels of continence (Kelly score). Five measures of emotional and behavioural adjustment were used to assess a number of domains of child/adolescent functioning and to include measures from multiple perspectives. The psychiatric assessment of the child identified a disorder in 29% of the group overall. Based on parental assessments, behavioural maladjustment was shown in 27% of the children, and on the basis of a self-report questionnaire 24% of the children were depressed. Behavioural adjustment as rated by teachers was similar to the norms. The level of continence achieved (total Kelly score) did not appear to influence psychological adjustment, with the exception of the incontinent young girls (6 to 11 years) who were shown to be less well adjusted than the continent young girls. Differences between children showing positive versus negative adjustment were dependent on the perspective of the respondent and were also related to the child's age and gender, age of achieving continence, frequency of accidents, and parental factors.

Biofeedback training is useful in fecal incontinence but disappointing in constipation

BACKGROUND

Successful biofeedback therapy has been reported in the treatment of fecal incontinence and constipation. It is uncertain which groups of incontinent patients benefit from biofeedback, and our impression has been that biofeedback is more successful for incontinence than for constipation.

PURPOSE

This study was designed to review the results of biofeedback therapy at the Lahey Clinic.

METHODS

Biofeedback was performed using an eight-channel, water-perfused manometry system. Patients saw anal canal pressures as a color bar graph on a computer screen. Assessment after biofeedback was by manometry and by telephone interview with an independent researcher.

RESULTS

Fifteen patients (13 women and 2 men) with incontinence underwent a mean of three (range, 1-7) biofeedback sessions. The cause was obstetric (four patients), postsurgical (five patients), and idiopathic (six patients). Complete resolution of symptoms was reported in four patients, considerable improvement in four patients, and some improvement in three patients. Manometry showed a mean increase of 15.3 (range, -3-30) mmHg in resting pressure and 35.7 (range, 13-57) mmHg in squeezing pressure after biofeedback. A successful outcome could not be predicted on the basis of cause, severity of incontinence, or initial manometry. Twelve patients (10 women and 2 men) with constipation underwent a mean of three (range, 1-14) biofeedback sessions. Each had manometric evidence of paradoxic nonrelaxing external sphincter or puborectalis muscle confirmed by defography or electromyography. All patients could be taught to relax their sphincter in response to bearing down. Despite this, only one patient reported resolution of symptoms, three patients had reduced straining, and three patients had some gain in insight.

CONCLUSIONS

Biofeedback helped 73 percent of patients with fecal incontinence, and its use should be considered regardless of the cause or severity of incontinence or of results on initial manometry. In contrast, biofeedback directed at correcting paradoxic external sphincter contraction has been disappointing.

Social and emotional impact of faecal incontinence after surgery for anorectal abnormalities

A significant proportion of children with anorectal malformations have long term problems with faecal continence. The psychological consequences of this chronic disability was assessed in 160 children and adolescents. The prevalence of clinically significant emotional problems among the sample overall, as assessed by a diagnostic psychiatric interview (19%), parental assessment (27%), and child self report depressive scale (24%) was higher than expected relative to normative populations. With the exception of the young girls (6-11 years), the incontinent children and adolescents were not judged to be less well adjusted than those with good bowel control. Treatment for anorectal malformations appears to be associated with an increased risk for behavioural and social problems, but this was not related to the level of continence. Parental factors and gender were significantly associated with outcome. These children and families would benefit from psychological evaluation and support especially during early childhood.

Bowel training in spina bifida: importance of education, patient compliance, age, and anal reflexes

Bowel incontinence is a major social impairment for 90% of patients with spina bifida. This study assess the bowel continence of children and young adults with spina bifida before and after a toileting intervention that emphasized patient/family education and a regular, consistently timed, reflex-triggered bowel evacuation. Bowel continence defined as one or fewer incontinent stools per month, rose from 13% (5/40) to 60% (24/40) following intervention. Twenty-four of the 35 initially incontinent patients were compliant. Seventy-nine percent (19/24) of the compliant subjects achieved continence whereas 0/11 of the noncompliant subjects achieved continence p < 0.0001). Presence of the bulbocavernosus (BC) and anocutaneous (AC) reflexes correlated significantly with achieving continence (either vs none p < .02, AC vs no AC p < .01). Instituting bowel training before age 7 correlated with improved outcomes by means of better compliance. Excluding noncompliant subjects, 83% (24/29) of the original sample of 40 patients satisfied our strict definition of bowel continence after this simple low technology intervention.

Spina bifida: the personal and financial cost of incontinence

Spina bifida is a congenital defect in the spinal column in which one or more vertebrae fail to form. The effect of spina bifida on continence is usually complicated by the effect of hydrocephalus on the ability to learn and master the necessary skills to overcome the problems. The childhood and adolescence of some individuals who have spina bifida has been ruined by professionals who chose to ignore the wider implications of severe congenital disability and its effects upon the child's education, personal and social development, and the quality of family life. A holistic approach to management, from birth onwards, should facilitate the interdisciplinary cooperation which is vital if these human tragedies are to be avoided.

Cognitive-behavioral treatment for panic disorder with gastrointestinal symptoms: a case study

A 25-year-old woman with a 12-year history of panic disorder with agoraphobia and gastrointestinal symptoms was treated using a cognitive-behavioral program which included: (a) correcting misconceptions about normal bowel functioning, (b) graduated in vivo exposure to internal stimuli which she misinterpreted as precursors of loss of bowel control, (c) graduated in vivo exposure to external stimuli associated with fears of loss of bowel control, (d) establishment of regular eating patterns, and (e) bowel control training. Self-ratings of avoidance and distress, frequency of panic attacks, diazepam use, and negative cognitions decreased with treatment. Treatment gains were maintained at 18-month follow-up. Tailoring of cognitive-behavioral treatment to panic with fears of loss of bowel control was emphasized.

Liquid stool incontinence with severe urgency: anorectal function and effective biofeedback treatment

The motor and sensory function of the anorectum is well characterised in patients with solid stool incontinence. Fewer data are available in the case of liquid stool incontinence. Anorectal sensorimotor function was studied in 16 patients with liquid stool incontinence and severe urgency (10 with diarrhoea) unresponsive to conventional medical treatment, and in 16 healthy volunteers. The only significant difference found between incontinent patients and controls was a reduction in squeeze duration (p < 0.0001). Fourteen patients were selected to receive biofeedback treatment. Treatment was associated with a substantial improvement in continence in 12 patients and with a significant decrease in urgency (p < 0.05). Bowel frequency was not significantly influenced. Most patients showed a persistent improvement in anal motor function. Functional parameters were not predictive of outcome of treatment; the poor responders showed major psychological problems. In conclusion, an anal motor deficit is often present in disabling liquid stool incontinence. Biofeedback may improve anal continence in 75% of patients.

[The defecation habits in a normal working population]

We have studied the bowel habits of a theoretically normal working population to know the range defecation patterns, characteristics and main factors that may influence it. We have designed a questionnaire composed of 80 questions and distributed to 837 people. Answers, were evaluated in 414 cases (187 men and 227 women), with a median age of 33 years (range 20-64 years). The average number of stools was 7.1 +/- 3.3 per week and in 62.4% of subjects they were between the range of 5 and 8. Bowel movements were less frequent in women than in men, and the same finding was seen about self-reported constipation; nevertheless there were no differences in regard to age. Laxatives were used regularly by 11.3%, and 36% referred straining at stool at least 25% of the time and 8.3% referred straining for loose stools. Alternating bowel function presented in 19.4% and functional abdominal pain in 28% with a female predominance. Faecal incontinence occurred in 6.8% of population; an important prevalence. We also analyse variables such as diet influence, physical activity, obstetrical, gynaecological and psychosocial factors. Although this survey has revealed that a normal bowel function is very variable, only a 7.5% of the subjects, consulted a doctor for bowel complaints.

MMPI assessment of patients with functional bowel disorders

This prospective study was undertaken to assess personality differences among patients with chronic pelvic floor disorders. Sixty patients (43 females and 17 males) of a mean age of 58 (range, 33-87) years with fecal incontinence (n = 19), constipation (n = 30), or levator spasm (n = 11) had a mean duration of symptoms of 35 (range, 2-50) years. The Minnesota Multiphasic Personality Inventory (MMPI) was utilized for psychologic assessment for all patients prior to treatment. Mean scores for scales 1 (hypochondriasis), 2 (depression), and 3 (hysteria) were significantly elevated for the levator spasm group (71, 75, and 73, respectively). A similar pattern was seen for the constipation group, where the mean scores for scales 1 and 2 were significantly elevated (70 and 74, respectively) with a moderate elevation on scale 3 (68). The hypochondriasis (1), depression (2), and hysteria (3) scales are referred to as the "neurotic triad," and profile patterns such as these indicate that these subjects may manifest their psychologic distress as physical symptoms. By contrast, the fecal incontinence patients were within the normal range on all scales. The information from these MMPI profiles can be used to understand the personality and emotional composition of these patients to assist in their evaluation and treatment.

Relationship between clinical symptoms of anal incontinence and the results of anorectal manometry

The aim of this work was to analyze clinical symptoms in light of anorectal manometry results. We compared the frequency of clinical symptoms in relation with the presence or absence of functional anomalies. Using this methodology, the following relationships may be suggested: the need to wear a pad, with a decreased resting pressure at the upper part of the anal canal; the inability to delay rectal evacuation, with decreased anal voluntary contraction; interference of incontinence with social activities, with decreased duration of anal voluntary contraction; urinary symptoms, with an increased threshold volume of rectal distention needed to elicit the rectoanal inhibitory reflex; and complete rectal prolapse, with reduced length of the anal canal.

[Psychosocial aspects of fecal incontinence]

Although fecal incontinence is one of the more frequent clinical symptoms of the gastrointestinal tract, its assessment is often neglected in clinical practice. The psychosocial aspects of the symptoms are also often overlooked: The number of undetected cases in comparison to those registered illustrates that not only patients but also physicians avoid this topic during clinical routine. Consequences of fecal incontinence for the quality of life of patients have rarely been investigated, but we could show that there are specific impacts of incontinence on family life, specifically with respect to sexuality, and on the job situation of those affected. Finally, it has been shown that in most cases continence can be achieved by management strategies deriving from psychological learning theory such as biofeedback training.

Sexual dysfunction amongst women with Crohn's disease: a hidden problem

The sexual problems of 50 women with Crohn's disease, of whom 45 had a stable relationship, were investigated by structured interview and compared with age-matched controls. Twenty-four percent patients had either infrequent or no intercourse compared with 4% of controls (chi 2 = 8.3, p < 0.005). However, amongst patients and controls who were sexually active, the frequency of intercourse was similar. Reasons for sexual inactivity included abdominal pain (24%), diarrhoea (20%) and fear of faecal incontinence (14%). Dyspareunia was common in patients (chi 2 = 6.5, p < 0.01) and this was irrespective of the site of disease (large vs. small bowel chi 2 = 0.85, NS). Women with perianal disease and fistulae were more likely to have dyspareunia than women with neither (chi 2 = 4.2, p < 0.05), although this was not so for less extensive involvement with only perianal disease (chi 2 = 2.8, NS) or fistulae (chi 2 = 0.8, NS). Vaginal candidiasis was more common in patients (chi 2 = 5.8, p < 0.02), and on occasions this may have contributed to dyspareunia. Women with Crohn's disease experience sexual problems much more than healthy controls and they need support, sympathetic investigation and management.

Incontinence and troublesome behaviors predict institutionalization in dementia

Factors predicting the early institutionalization of demented patients were studied in 143 outpatients using univariate and multivariate life-table methods. Four types of factors were evaluated for prognostic value: severity of functional impairment, behavioral disorders, individual patient characteristics, and type of caregiver. After follow-up of 19 +/- 12 months, 51 patients had been institutionalized. Increased global severity of dementia, the presence of troublesome and disruptive behaviors, and incontinence increased the likelihood of institutionalization. The best predictors of institutionalization were paranoia, aggressive behavior, and incontinence. Neither individual patient characteristics (age, education, and gender) nor caregiver relationship to the patient (male spouse, female spouse, and male or female child) influenced institutionalization. Since troublesome behavioral disorders are potentially treatable aspects of dementia leading to institutionalization, their management should be a major focus of therapy in dementia.

Bowel and bladder control of children with myelomeningocele: a Nordic study

The urinary and bowel control was studied of 527 children with myelomeningocele aged between four and 18 years. Information was obtained from medical records and by parent questionnaire. 44 had normal urinary control, 50 had a urinary diversion and the remaining 433 had neuropathic bladder without urinary diversion, of whom 31 per cent expressed their bladder manually and 40 per cent used clean intermittent catheterisation (CIC). 60 per cent needed assistance emptying their bladder. Children using CIC were more continent and needed less help, but were more often treated with antibiotics. Of the 527 children, 412 had disturbed bowel control. 212 evacuated their bowels manually, of whom 90 per cent needed assistance. Parents judged urinary incontinence to be very stressful for 37 per cent of the children and faecal incontinence for 33 per cent. The authors conclude that social urinary continence should be defined as the ability to keep dry for three hours or more.

Sphincter repair without overlapping for fecal incontinence

Forty patients who had sphincter repair by one surgeon over the last 15 years were reviewed. The etiology of sphincter trauma was previous surgery (22), childbirth (14), and accidental trauma (4). Eleven patients had undergone at least one previous attempt at repair. Prior to operation, 12 patients were incontinent for liquid stool and 28 for formed stool. A technique of sphincter repair without overlapping was used. An associated diverting colostomy was carried out on seven patients who had had a previous failed repair. Follow-up was an average of 17 months after operation (range, 2-96 months). After operation, 25 patients were completely continent, 6 had occasional leaks of liquid stool, 4 were continent for solid stool only, and 5 showed no improvement. Neither diverting colostomy nor overlapping sutures appear to be mandatory for a successful repair of the anal sphincter after trauma.

Transanal electrostimulation for fecal incontinence: clinical, psychologic, and manometric prospective study

A prospective study was carried out to analyze the clinical, psychologic, and manometric short-term results of transanal electrostimulation (TES) in the treatment of fecal incontinence. Fifteen patients underwent TES. An initial clinical and manometric assessment was carried out before and 1 month after the procedure. A psychologic evaluation was also performed by means of interviews and appropriate tests. Early improvement of symptoms was noted in 10 patients. The nonresponders were women with gross daily incontinence to solid stool. At anal manometry, resting tone and rectal sensation remained unchanged, whereas a significant increase of voluntary contraction was observed following TES (from 48 +/- 26 to 59 +/- 39 mm Hg, P = 0.03). Psychologically, TES led to a significant decrease of both latent and paranoid anxiety related to symptoms (P = 0.02). At a clinical reassessment 6 months later, one of the nonresponders became continent after a further course of TES. In conclusion, TES is well accepted by the patients, is followed by positive emotional response, and, by improving striated sphincter function, seems to be effective in the treatment of partial fecal incontinence.

Animal illness and human emotion. Decision-making concerning pets with loss of autonomic function

Appropriate communication with clients is essential when dealing with pets that have conditions associated with loss of autonomic function. These conditions include fecal and urinary incontinence, megaesophagus, and feline constipation. These conditions require a strong commitment to long-term caretaking with frequent frustrations on behalf of the client. Evaluation of the owner's personality types as well as the entire home situation is essential in assisting clients with their decision on how to deal with the problems. Each case should be evaluated based on multiple factors. Ideally, the veterinarian needs to go beyond offering medical advice and should help facilitate the decision-making process based on the ability of the client to deal with the care of a pet with a chronic problem. Different approaches to dealing with these often difficult situations will be discussed.

Paradoxical approach to the management of faecal incontinence in normal children

Three children with faecal incontinence, in whom conventional treatment had failed, were managed with a regimen that focuses on the symptoms and present behaviour. It is short term and uses a paradoxical approach.

Faecal incontinence in childhood: a multidisciplinary approach including biofeedback

One hundred and seven children with faecal incontinence were evaluated and managed over a 3 year period by a multidisciplinary team. After initial clinical assessment, evaluation of defaecatory mechanisms (using a balloon model) and assessment of personal-social development and self-concept were undertaken. Management was based on initial bowel evacuation, short-term laxatives, and habit training involving systematic use of positive reinforcement; 69 children received biofeedback conditioning. Idiopathic megacolon with constipation and soiling was the most common finding (98 cases). Other diagnoses included previously undiagnosed neurogenic bowel (three cases), post-surgical and anomalies (four cases), and psychogenic encopresis (two cases). Idiopathic megacolon was characterized by decreased rectal sensation, increased threshold for external sphincter relaxation and an inability to evacuate. Faecal incontinence was associated with an undesirably low social self-concept (70% of the 40 evaluated), but was not related to a delay in development (mean general developmental quotient = 105 +/- 8, for the 35 tested). Family psychopathology warranting referral for family therapy was found in 14 children (13%). The management programme yielded a short-term (3 months) cure rate of 68% and a long-term (12 months) cure rate of 90%, with 10% having continued soiling which varied from occasional to several incidents/week. No significant improvement in self-concept was observed overall, although marked improvements were observed in some children. We conclude that disordered defaecatory dynamics are a major determinant of faecal incontinence in children. Undesirably low social self-concepts but normal developmental ability accompany this condition. Management is facilitated by a multidisciplinary approach, acknowledging the role of both behavioural and physiological components of the problem.(ABSTRACT TRUNCATED AT 250 WORDS)

Psychiatric screening for patients with faecal incontinence or chronic constipation referred for surgical treatment

Fifty patients attending for surgical treatment of chronic constipation (n = 21) or faecal incontinence (n = 29) were studied using two psychiatric screening tests: the Hospital Anxiety and Depression (HAD) scale and the General Health Questionnaire (GHQ). Each patient was assessed preoperatively and 6-12 months postoperatively. Results were compared with age and sex-matched controls (n = 50). Constipated patients had significantly higher HAD depression scores compared with controls (median and range): 6 (2-12) versus 4 (0-8), P less than 0.05. Constipated patients who were improved by operation (n = 13) had significantly lower preoperative HAD anxiety scores compared with those who were not improved (n = 8): 8 (3-14) versus 15 (10-19), P less than 0.01; they also had significantly lower HAD depression scores: 4 (2-12) versus 7 (5-11), P less than 0.05. Using these parameters incontinent patients did not differ from controls, but patients who had a bad result after operation (n = 15) had significantly higher HAD anxiety scores than those who obtained clinical benefit (n = 14): 10 (2-15) versus 6 (2-12), P less than 0.05; HAD depression scores were also greater: 5 (2-15) versus 3 (0-9), P less than 0.05; and GHQ scores were greater: 12 (0-47) versus 4 (0-41), P less than 0.05.