Community-based prevalence of anal incontinence

Faecal incontinence after chemoradiotherapy in anal cancer survivors: long-term results of a national cohort

PURPOSE

To examine the prevalence and severity of faecal incontinence amongst anal cancer survivors after chemoradiotherapy.

MATERIAL AND METHODS

Anal cancer survivors from a complete, unselected, national cohort, minimum 2-years follow-up, were invited to a cross-sectional study. The St. Mark's incontinence score was used to evaluate occurrence and degree of faecal incontinence the last four weeks. The results were compared to age- and sex-matched volunteers from the general population.

RESULTS

Of 199 invited survivors and 1211 volunteers, 66% and 21%, respectively, signed informed consent. The survivors had significantly higher St. Mark's score than the volunteers (mean 9.7 vs. 1.1, p<0.001). Incontinence of stool of any degree was reported by 43% vs. 5% (OR 4.0, CI 2.73-6.01), and urgency was reported by 64% vs. 6% (OR 6.6, CI 4.38-9.90) of the survivors and volunteers, respectively. Only 29% of those with leakage of liquid stool used constipating drugs. Survivors of locally advanced tumours had a higher incontinence score (p<0.01).

CONCLUSIONS

Moderate to severe faecal incontinence is common amongst anal cancer survivors. Post-treatment follow-up should include the evaluation of continence, and incontinent survivors should be offered better symptom management and multidisciplinary approach if simple measures are insufficient.

Racial differences in fecal incontinence in community-dwelling women from the EPI study

OBJECTIVES

Despite its prevalence and associated distress, fecal incontinence (FI) is not well understood. There are limited data regarding associations between FI and race. The goal of this study was to estimate the prevalence of FI, and to secondarily identify demographic, lifestyle, and medical factors associated with FI, especially with regard to race.

METHODS

This was a planned secondary analysis of a population-based cross-sectional telephone interview survey of 2812 black and white community-dwelling women living in southeastern Michigan. The primary outcome measured was the prevalence of self-reported FI, defined as any loss of stool during the previous 12 months. Logistic regression modeling was used to identify characteristics independently associated with FI.

RESULTS

Of the subjects, 16.7% reported FI in the previous year. Fecal incontinence was approximately twice as common in white women (20%) as black women (11%). Factors associated with FI differed between the 2 races, although its prevalence in both racial groups increases with higher numbers of medical comorbidities, increased frequency of bowel movements per week, and depression.

CONCLUSIONS

One in 6 women report FI, although it occurs one-half as often in black as in white women. Although there are common characteristics shared by women with FI in both racial groups, white women experience FI in complex with other pelvic floor disorders. For black women, FI is an isolated pelvic floor disorder associated with mobility impairment.

Surgery for faecal incontinence in adults

BACKGROUND

Faecal incontinence is a debilitating problem with significant medical, social and economic implications. Treatment options include conservative, non-operative interventions (for example pelvic floor muscle training, biofeedback, drugs) and surgical procedures. A surgical procedure may be aimed at correcting an obvious mechanical defect, or augmenting a functionally deficient but structurally intact sphincter complex.

OBJECTIVES

To assess the effects of surgical techniques for the treatment of faecal incontinence in adults who do not have rectal prolapse. Our aim was firstly to compare surgical management with non-surgical management and secondly, to compare the various surgical techniques.

SEARCH METHODS

Electronic searches of the Cochrane Incontinence Group Specialised Register (searched 6 March 2013), the Cochrane Colorectal Cancer Group Specialised Register (searched 6 March 2013), CENTRAL (2013, issue 1) and EMBASE (1 January 1998 to 6 March 2013) were undertaken. The British Journal of Surgery (1 January 1995 to 6 March 2013), Colorectal Diseases (1 January 2000 to 6 March 2013) and the Diseases of the Colon and Rectum (1 January 1995 to 6 March 2013) were specifically handsearched. The proceedings of the Association of Coloproctology of Great Britain and Ireland annual meetings held from 1999 to 2012 were perused. Reference lists of all relevant articles were searched for further trials.

SELECTION CRITERIA

All randomised or quasi-randomised trials of surgery in the management of adult faecal incontinence (other than surgery for rectal prolapse).

DATA COLLECTION AND ANALYSIS

Three review authors independently selected studies from the literature, assessed the methodological quality of eligible trials and extracted data. The three primary outcome measures were change or deterioration in incontinence, failure to achieve full continence, and the presence of faecal urgency.

MAIN RESULTS

Nine trials were included with a total sample size of 264 participants. Two trials included a group managed non-surgically. One trial compared levatorplasty with anal plug electrostimulation and one compared an artificial bowel sphincter with best supportive care. The artificial bowel sphincter resulted in significant improvements in at least one primary outcome but the numbers were small. The other trial showed no difference in the primary outcome measures.Seven trials compared different surgical interventions. These included anterior levatorplasty versus postanal repair, anterior levatorplasty versus total pelvic floor repair, total pelvic floor versus postanal repair, end to end versus overlap sphincter repair, overlap repair with or without a defunctioning stoma or with or without biofeedback, and total pelvic floor repair versus repair plus internal sphincter plication and neosphincter formation versus total pelvic floor repair. Sacral nerve stimulation and injectables are considered in separate Cochrane reviews. Only one comparison had more than one trial (total pelvic floor versus postanal repair, 44 participants) and no trial showed any difference in primary outcome measures.

AUTHORS' CONCLUSIONS

The review is striking for the lack of high quality randomised controlled trials on faecal incontinence surgery that have been carried out in the last 10 years. Those trials that have been carried out have focused on sacral neuromodulation and injectable bulking agents, both reported in separate reviews. The continued small number of relevant trials identified together with their small sample sizes and other methodological weaknesses limit the usefulness of this review for guiding practice. It was impossible to identify or refute clinically important differences between the alternative surgical procedures. Larger rigorous trials are still needed. However, it should be recognised that the optimal treatment regime may be a complex combination of various surgical and non-surgical therapies.

Prevalence and Risk Indicators for Anal Incontinence among Pregnant Women

The aim of this study was to assess the prevalence and risk factors of anal incontinence in an unselected pregnant population at second trimester. A survey of pregnant women attending a routine ultrasound examination was conducted in a university hospital in Oslo, Norway. A questionnaire consisting of 105 items concerning anal incontinence (including St. Mark's score), urinary incontinence, medication use, and comorbidity was posted to women when invited to the ultrasound examination. Results. Prevalence of self-reported anal incontinence (St. Mark's score ≥ 3) was the lowest in the group of women with a previous cesarean section only (6.4%) and the highest among women with a previous delivery complicated by obstetric anal sphincter injury (24.4%). Among nulliparous women the prevalence of anal incontinence was 7.7% and was associated to low educational level and comorbidity. Prevalence of anal incontinence increased with increasing parity. Urinary incontinence was associated with anal incontinence in all parity groups. Conclusions. Anal incontinence was most frequent among women with a history of obstetric anal sphincter injury. Other obstetrical events had a minor effect on prevalence of anal incontinence among parous women. Prevention of obstetrical sphincter injury is likely the most important factor for reducing bothersome anal incontinence among fertile women.

Role of bariatric surgery in the pelvic floor disorders

Pelvic floor disorders are very frequent among women. Weight loss can help them to achieve urinary and faecal continence again. In this narrative review, the possible mechanisms of pelvic floor disorders in obese women, their symptoms and the role of bariatric surgery in changing their quality of life are presented. We retrieved the included results of our study after performing a systematic, electronic search in PubMed (December 17, 2012) and Scopus (December 17, 2012). The main mechanism causing the development of pelvic floor disorders is chronically increased abdominal pressure as it overts structural damage or neurologic dysfunction predisposing to prolapse and incontinence. The symptoms include a sensation of vaginal fullness or pressure, uterine descent, sacral back pain with standing, vaginal spotting from ulceration of the protruding cervix or vagina, coital difficulty, lower abdominal discomfort, and voiding and defecatory difficulties. Evidence indicates that massive weight loss (45 to 50 kg) improves incontinence in morbidly obese women after bariatic surgery. Faecal incontinence is also improved after bariatric surgery. This review highlights the role of bariatric surgery in weight reduction of obese women that could act as a treatment for the pelvic floor disorders faced by those women offering improvement in incontinence as well as quality of life.

Long-term efficacy of dextranomer in stabilized hyaluronic acid (NASHA/Dx) for treatment of faecal incontinence

AIM

Randomized, controlled trials have demonstrated the efficacy and safety of injectable bulking agents for the treatment of faecal incontinence (FI), although the long-term outcome has not been assessed. NASHA/Dx gel, a biocompatible, nonallergenic bulking agent consisting of nonanimal stabilized hyaluronic acid and dextranomer microspheres, has demonstrated efficacy and safety for up to 12 months after treatment. The objective of this study was to evaluate the long-term efficacy and safety of NASHA/Dx, assessed 24 months after treatment.

METHOD

This study was a 24-month follow-up assessment of patients treated with NASHA/Dx under open-label conditions. Data on FI episodes and quality of life measures were collected from diaries over the 28-day period immediately preceding the 24-month assessment. Adverse events were collected.

RESULTS

Eighty-three of 115 patients completed the 24-month follow-up assessment. At 24 months, 62.7% of patients were considered responders and experienced a ≥ 50% reduction in the total number of FI episodes. The median number of FI episodes declined by 68.8% (P < 0.001). Episodes of both solid and liquid stool incontinence decreased. The mean number of incontinence-free days increased from 14.6 at baseline to 21.7 at 24 months (P < 0.001). Incontinence scores and FI quality of life scores also showed significant improvements. The most common adverse events (AEs) were proctalgia (13.3%) and pyrexia (9.6%). The majority of AEs were mild to moderate, self-limited and resolved within 1 month of the injection.

CONCLUSION

NASHA/Dx is safe, effective and durable over a 24-month period with a majority of patients experiencing significant improvement in multiple symptoms associated with FI.

A review of posterior tibial nerve stimulation for faecal incontinence

AIM

This review aimed to assess the published results of posterior tibial nerve stimulation (PTNS) for faecal incontinence.

METHOD

A search was performed of PubMed, MEDLINE and Embase to identify studies describing the clinical outcome of PTNS for faecal incontinence.

RESULTS

Thirteen studies were identified. These described the outcome of PTNS for faecal incontinence in 273 patients. Four described transcutaneous PTNS, eight percutaneous PTNS and one compared both methods of PTNS with a sham transcutaneous group. One investigated patients with faecal incontinence and spinal cord injury and another with inflammatory bowel disease. There was marked heterogeneity of the treatment regimens and of the end points used. All reported that PTNS improved faecal incontinence. A > 50% improvement was reported in episodes of faecal incontinence in 63-82% of patients. An improvement was seen in urgency (1-5 min). Improvement was also described in the Cleveland Clinic faecal incontinence score in eight studies. Patients with urge and mixed incontinence appear to benefit more than those with passive incontinence. Treatment regimens ranged in duration from 1-3 months. A residual therapeutic effect is seen after completion of treatment. Follow-up ranged from 1-30 months.

CONCLUSION

PTNS is effective for faecal incontinence. However, many of the published studies are of poor quality. Comparison between studies is difficult owing to differences in the outcome measures used, technique of PTNS and the timing and duration of treatment.

Sacral nerve stimulation in the treatment of severe faecal incontinence: long-term clinical, manometric and quality of life results

BACKGROUND

Faecal incontinence (FI) is a complex and multifactorial health problem. Treatment has to be individualised, analysing the aetiology and gravity in every case. Sacral nerve stimulation (SNS) has been shown to effectively improve treatment of FI.

METHODS

Fifty patients with severe FI treated with SNS between March 2002 and December 2010 were analysed. Preoperative assessment included physical examination, anorectal manometry and anal endosonography. Anal continence was evaluated using the Wexner continence grading system. Quality of life was evaluated using the Fecal Incontinence Quality of life Scale (FIQLS). Follow-up appointments were scheduled at 1, 6 and 12 months and annually thereafter. Wexner score, FIQLS and the ability to defer defecation were assessed at each visit.

RESULTS

Fifty patients underwent a permanent implant. The overall mean follow-up period was 55.52 ± 31.84 months. After 6 months, SNS significantly improved FI and positively impacted quality of life, as evidence by significant improvements in all 4 scales of the FIQLS. Anorectal manometry showed a trend towards an increase in maximum resting pressure and maximum pressure. After the first assessment at 6 months, Wexner score and FIQLS remained stable. Ability to defer defecation was also maintained. During follow-up, 3 patients (6 %) experienced implant site pain and episodes of extremity pain and paresthesias that were refractory to medical management and required device explantation. The implant site infection rate was 2 %.

CONCLUSIONS

Analysis of our long-term results confirms the safety and effectiveness of SNS in the management of patients with FI.

Injection of porous polycaprolactone beads containing autologous myoblasts in a dog model of fecal incontinence

PURPOSE

Few studies have examined whether bioengineering can improve fecal incontinence. This study designed to determine whether injection of porous polycaprolactone beads containing autologous myoblasts improves sphincter function in a dog model of fecal incontinence.

METHODS

The anal sphincter of dogs was injured and the dogs were observed without and with (n = 5) the injection of porous polycaprolactone beads containing autologous myoblasts into the site of injury. Autologous myoblasts purified from the gastrocnemius muscles were transferred to the beads. Compound muscle action potentials (CMAP) of the pudendal nerve, anal sphincter pressure, and histopathology were determined 3 months after treatment.

RESULTS

The amplitudes of the CMAP in the injured sphincter were significantly lower than those measured before injury (1.22 mV vs. 3.00 mV, P = 0.04). The amplitudes were not different between dogs with and without the injection of autologous myoblast beads (P = 0.49). Resting and squeezing pressures were higher in dogs treated with autologous myoblast beads (2.00 mmHg vs. 1.80 mmHg; 6.13 mmHg vs. 4.02 mmHg), although these differences were not significant in analyses of covariance adjusted for baseline values. The injection site was stained for smooth muscle actin, but showed evidence of foreign body inflammatory reactions.

CONCLUSION

This was the first study to examine whether bioengineering could improve fecal incontinence. Although the results did not show definite evidence that injection of autologous myoblast beads improves sphincter function, we found that the dog model was suitable and reliable for studying the effects of a potential treatment modality for fecal incontinence.

Factors associated with quality of life among women with fecal incontinence

INTRODUCTION AND HYPOTHESIS

Fecal incontinence (FI) is a distressing, highly prevalent condition affecting quality of life (QOL). The aim of our study was to identify predictors of moderate/severe health-related QOL among women with FI.

METHODS

Data were collected from women presenting to a multispecialty clinic from January 2005 to July 2009 with FI. All completed questionnaires on demographics and validated instruments including the Fecal Incontinence Quality of Life Instrument (FIQL), Patient Health Questionnaire (PHQ) for depression, and Fecal Incontinence Severity Index (FISI). Logistic regression was used to identify factors associated with moderate/severe FI.

RESULTS

The study included 226 women with an average age of 59.2 years (SD = 14.1); 92 % were Caucasian, 67 % were married, and the average body mass index was 30.0 (SD = 8.6). Their QOL was moderately/severely affected by FI in 35.6 %. Mean overall FIQL score was 2.5 (SD = 0.8). Median QOL subscale measures were: lifestyle = 2.7 (SD = 1.0), coping = 2.09 (SD = 0.9), depression = 2.8 (SD = 1.0), and embarrassment = 2.2 (SD = 0.9). Average FISI score was 31.6 (SD = 15.7) and average depression score on the PHQ was 8.93 (SD = 8.1). In univariate analyses, diabetes, irritable bowel symptoms, prior hysterectomy, history of previous medical care for FI, higher FISI and PHQ scores were associated with moderate/severe FIQL scores (p < 0.05). Higher PHQ scores and prior hysterectomy significantly predicted moderate/severe QOL in logistic regression analysis (p < 0.05).

CONCLUSIONS

We confirm that women with higher depression scores and prior hysterectomy have moderate/severe QOL impairment. When evaluating FI, screening for depression should be undertaken.

Factors associated with symptom severity in women presenting with fecal incontinence

BACKGROUND

Fecal incontinence (FI) affects 2-12% of the US population. Identification of factors associated with worsening symptoms has important implications for prevention and treatment.

OBJECTIVE

The aim of our study is to assess factors associated with symptom severity in women presenting with FI.

DATA SOURCES

This was a prospective survey study.

STUDY SELECTION

Patients presenting to the Michigan Bowel Control Program Clinic for FI were prospectively enrolled between May 2005 and May 2009.

MAIN OUTCOME MEASURES

Factors associated with fecal incontinence severity.

RESULTS

Data on 231 women was analyzed with a mean age of 59.2 years (SD = 14.2) and mean BMI of 30.0 (SD = 8.6); 92% were white. Mean FISI score was 32.4 (SD = 15.3). Two-thirds of patients had a type 1-4 stool on the Bristol stool scale. Forty-one percent of subjects complained of urinary incontinence, 56.2% had an episiotomy, 29% had an operative delivery, and 15.1% reported a severe laceration with childbirth. The majority of patients (86.1%) reported FI for greater than 1 year, and 65.4% had previously sought care for FI. Bivariate analysis revealed that diabetes, IBS, urinary incontinence, history of operative delivery or severe laceration, fecal urgency, longer history of symptoms, previous health care for FI, and belief in treatment were positively associated with worse FISI score. In multiple linear regression analysis, increased FI symptom severity was shown to be associated with fecal urgency (0.0004), history of episiotomy (0.04), urinary incontinence (0.02), and diabetes mellitus (0.004).

LIMITATIONS

This was a cross-sectional survey study performed at a Tertiary care center.

CONCLUSION

Patients with a history of episiotomy, diabetes, urinary incontinence, and fecal urgency have increased FI symptom severity. Proactive screening of patients with these medical histories is needed.

Risk factors for fecal incontinence in older women

OBJECTIVES

The objectives of this study were to estimate the prevalence of fecal incontinence (FI) in older women and examine associations between potential risk factors and prevalent FI.

METHODS

We conducted a cross-sectional study of prevalent FI in 64,559 women, aged 62-87 years, in the Nurses' Health Study. Since 1976, participants provided information on health and lifestyle on mailed biennial questionnaires. Data on FI were collected in 2008. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for FI were calculated using logistic regression models.

RESULTS

The reported prevalence of liquid or solid stool incontinence at least monthly increased from 9% in women aged 62 to 64 years to 17% in women aged 85 to 87 years. Prevalent FI was 50% less common in black women compared with white women (6% vs. 12%, respectively). Other variables associated with increased odds of FI at least monthly were pregnancy, higher body mass index (BMI), lower physical activity, functional limitations, current cigarette smoking, type 2 diabetes, high blood pressure, and neurologic disease. Urinary incontinence (UI) was a strong correlate of FI, with 63% of women with FI reporting UI at least monthly compared with 45% of women in the whole study population.

CONCLUSIONS

FI is a common condition among older women, and often co-occurs with UI. Potentially modifiable risk factors include BMI, physical activity, and cigarette smoking.

Electrical stimulation and biofeedback for the treatment of fecal incontinence: a systematic review

PURPOSE

This systematic review determines the best known form of biofeedback (BF) and/or electrical stimulation (ES) for the treatment of fecal incontinence in adults and rates the quality of evidence using the Grades of Recommendation, Assessment, Development, and Evaluation. Attention is given to type, strength, and application mode of the current for ES and to safety.

METHODS

Methods followed the Cochrane Handbook. Randomized controlled trials were included. Studies were searched in The Cochrane Library, MEDLINE, and EMBASE (registration number (PROSPERO): CRD42011001334).

RESULTS

BF and/or ES were studied in 13 randomized parallel-group trials. In 12 trials, at least one therapy group received BF alone and/or in combination with ES, while ES alone was evaluated in seven trials. Three (four) trials were rated as of high (moderate) quality. Average current strength was reported in three of seven studies investigating ES; only two studies reached the therapeutic window. No trial showed superiority of control, or of BF alone or of ES alone when compared with BF + ES. Superiority of BF + ES over any monotherapy was demonstrated in several trials. Amplitude-modulated medium-frequency (AM-MF) stimulation, also termed pre-modulated interferential stimulation, combined with BF was superior to both low-frequency ES and BF alone, and 50 % of the patients were continent after 6 months of treatment. Effects increased with treatment duration. Safety reporting was bad, and there are safety issues with some forms of low-frequency ES.

CONCLUSIONS

There is sufficient evidence for the efficacy of BF plus ES combined in treating fecal incontinence. AM-MF plus BF seems to be the most effective and safe treatment.

KEY MESSAGES

• The higher the quality of the randomized trial the more likely was a significant difference between treatment groups. • Two times more patients became continent when biofeedback was used instead of a control, such as pelvic floor exercises. • Two times more patients became continent when biofeedback plus electrical stimulation was used instead of biofeedback only. • Low-frequency electrical stimulation can have adverse device effects, and this is in contrast to amplitude-modulated medium-frequency electrical stimulation. • There is high quality evidence that amplitude-modulated medium-frequency electrical stimulation plus electromyography biofeedback is the best second-line treatment for fecal incontinence.

Cost-effectiveness analysis of sacral neuromodulation for faecal incontinence in The Netherlands

AIM

Sacral neuromodulation (SNM) plays a major part in the algorithm of management of faecal incontinence, but there are limited data on its cost-effectiveness. This study aimed to analyse this and the quality-adjusted life-years (QALYs) associated with two different treatment algorithms. The first (SNM-) included use of an artificial sphincter [dynamic graciloplasty (DGP) (50%) and artificial bowel sphincter (ABS) (50%)]. The second (SNM+) included SNM (80% of cases) and artificial sphincter (DGP 10%; ABS 10%) The incidence of sphincteroplasty was assumed to be equal in both algorithms.

METHOD

A Markov model was developed. A hypothetical cohort of patients was run through both strategies of the model. A mailed EuroQoL-5D questionnaire was used to determine health-related quality of life. Costs were reproduced from the Maastricht University Medical Centre prospective faecal incontinence database. The time scale of the analysis was 5 years.

RESULTS

The former treatment protocol cost €22,651 per patient and the latter, after the introduction of SNM, cost €16,473 per patient. The former treatment protocol resulted in a success rate of 0.59 after 5 years, whereas with the introduction of SNM this was 0.82. Adhering to the former treatment protocol yielded 4.14 QALYs and implementing the latter produced 4.21 QALYs.

CONCLUSION

The study demonstrated that introducing SNM in the surgical management algorithm for faecal incontinence was both more effective and less costly than DGP or ABS without SNM. This justifies adequate funding for SNM for patients with faecal incontinence.

Psychological impact and risk factors associated with new onset fecal incontinence

OBJECTIVES

We aim to evaluate the psychological impact and risk factors associated with new onset FI over 12 years in adults over 18 years for the first time in a population-based study.

METHODS

Participants (n = 1775) were a random population sample from Penrith, Australia who responded to a survey in 1997 and completed a 12-year follow-up survey (response rate = 60%). FI was defined as having leakage of stool over the past 12 months. The original and follow-up surveys contained valid questions on demographic, gastrointestinal and psychological symptoms.

RESULTS

114 (11.4%) reported new onset FI at the 12 year follow-up. People who reported FI at the 12 year follow-up were significantly more anxious and depressed. In terms of baseline risk factors only bloating (OR = 1.3; 95%CI 1.0-1.6, P = 0.026) was an independent predictor of developing new onset FI. However, current bowel symptoms measured at follow-up including less likelihood of <3 bowel motions a week, increased urgency and mucus were independently associated with having FI at follow-up.

CONCLUSION

FI is associated with anxiety and depression. Baseline GI symptoms do not appear to be as important as current bowel symptoms in determining who develops FI.

Pelvic floor disorders among women in Dabat district, northwest Ethiopia: a pilot study

INTRODUCTION AND HYPOTHESIS

Pelvic floor disorders affect many women in high-income countries. Since little is known about such disorders in Africa, this study aimed at assessing the prevalence and risk factors in an Ethiopian community. We also assessed the validity of a prolapse questionnaire.

METHODS

A community-based cross-sectional study was conducted among 395 women, recruited by a systematic random sampling technique. Women were interviewed about symptoms of urinary incontinence, faecal incontinence and pelvic organ prolapse by female nurses. Additionally, pelvic examinations were performed in 294 (74.2%) participants to assess anatomical prolapse using the simplified Pelvic Organ Prolapse Quantification staging system. Descriptive statistics and logistic regression analyses were employed.

RESULTS

The median age of participants was 35.0 years. Thirty-one women reported urinary incontinence (7.8%), 25 (6.3%) symptomatic pelvic organ prolapse and 2 (0.5%) faecal incontinence. Anatomical pelvic organ prolapse stage II-IV was detected in 162 (55.1%) of women who underwent pelvic examination. The questionnaire for prolapse assessment had poor validity (38.3% sensitivity and 95.4% specificity) even in cases of clinically relevant prolapse (stage III or IV). After adjustment, carrying heavy objects for 5 or more hours a day, history of prolonged labour and highland rural residence were associated with anatomical pelvic organ prolapse.

CONCLUSIONS

Self-reported incontinence seems low in northwest Ethiopia. The prevalence of symptomatic prolapse was low despite a high prevalence of prolapse signs. Notably, heavy carrying and prolonged labour increased the risk of anatomical prolapse stage II-IV. The methods of assessing pelvic floor disorders in a low-income context need further development.

Quality of life impact in women with accidental bowel leakage

BACKGROUND

Accidental bowel leakage (ABL) is associated with negative impact on quality of life (QoL) and many women do not seek care.

OBJECTIVES

To assess current perspectives and QoL among women with ABL; to identify factors associated with severe impact on condition-specific QoL; and to describe care-seeking for ABL.

DESIGN, SETTING AND PARTICIPANTS

Sub-analysis of 1096 women with ABL identified through an internet-based, self-administered survey of 5817 US women ≥ 45 years old.

MAIN OUTCOME MEASURE

Severe impact on QoL was defined as response of 'affects very much' or 'greatly' to any of seven domains within Pelvic Floor Impact Questionnaire.

RESULTS

QoL data were available for 85.6% (938/1096) of women with ABL. Domains relating to frustration, emotional health and participation in social activities demonstrated the greatest negative impact, with 39.2% (95% CI 36.1-42.4%) having overall severe impact. More frequent ABL, faecal urgency, nocturnal bowel movements, FI without warning, stress FI, weekly urinary incontinence and underlying bowel disorder were associated with severe impact on QoL. Of the 28.6% (268/938) of women who spoke to a physician about their ABL, the majority did so with a general practitioner or family physician (56.0%, 150/268). Only 19.0% (51/268) consulted an internist or gastroenterologist [27.2% (73/268)].

CONCLUSIONS

Nearly 40% of adult women with ABL have severe negative impact on QoL, but less than one-third seek care. More than half of those who seek care do so with their primary care provider. Improved awareness of the prevalence and impact of FI by these providers may decrease barriers and improve QoL.

Accidental bowel leakage in the mature women's health study: prevalence and predictors

BACKGROUND

The 2007 National Institutes of Health incontinence consensus panel emphasised the need for classification and identification of persons at risk for faecal incontinence (FI).

OBJECTIVES

To explore the prevalence of FI; to characterise severity and 'bother'; and to identify factors associated with FI in a large sample of community-dwelling women.

DESIGN, SETTING, AND PARTICIPANTS

A cohort of US women ≥ 45 years old was surveyed via an internet-based questionnaire between September 2009 and April 2010.

MAIN OUTCOME MEASURE

Accidental leakage of liquid or solid stool at least once in the last 12 months.

KEY RESULTS

Eighty-five per cent of those surveyed (5817/6873) participated and were predominantly white, well educated and insured. The prevalence of FI at least once in the past year was 18.8% (1096/5817; 95% CI: 17.8-19.9%) and 97% of these women were bothered by this frequency of leakage. Among 938 respondents with FI, 71.1% (667) preferred the term 'accidental bowel leakage' (ABL) over faecal or bowel incontinence. Bowel disorders, urinary incontinence, stroke, age 55-64, diabetes mellitus and prior vaginal delivery were associated with an increased odds of FI, whereas being married, Black or American Indian/Alaska Native race/ethnicity, and income ≥ $40,000 per year were associated with a decreased odds of FI.

CONCLUSIONS

Nearly one-fifth of mature US women suffer from bothersome leakage of stool at least yearly and the overwhelming majority prefer the term 'Accidental Bowel Leakage.' Those with bowel disorders and urinary incontinence are most likely to experience ABL. Incorporating questions regarding ABL or bowel and bladder disorders into routine screening may aid in identifying silent sufferers of ABL.

Fecal incontinence in the elderly: FAQ

Fecal incontinence (FI) is a common gastrointestinal (GI) complaint in patients aged 65 years and older. This evidence-based review article discusses the epidemiology, pathophysiology, evaluation, and management of FI in the geriatric population. We emphasize aging-related changes leading to and impacting evaluation and treatment of this symptom while incorporating the core geriatric principles of functional status and management aligned with patient preference and goals of care.

Outcomes and feasibility of laparoscopic sacrocolpopexy among obese versus non-obese women

OBJECTIVE

To compare complication rates and short-term outcomes of laparoscopic sacrocolpopexy among obese and non-obese women.

METHODS

A retrospective multicenter study of 39 obese women and 111 non-obese women was conducted. Obesity was defined as a body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) above 30. Operative parameters (length of operation, associated procedures, complication rate, and length of hospitalization) and short-term (2 months) objective and subjective results were evaluated.

RESULTS

The median BMI in the obese group was 30.5 (interquartile range [IQR] 30-32) versus 23 (IQR 21-25) in the non-obese group (P<0.0001). Short-term anatomic results (postoperative stage of prolapse) were comparable in the obese and non-obese groups: stage 0-1, 87.1% versus 91.6% (P=0.60); stage 2, 10.2% versus 5.5% (P=0.60); stage 3-4, 2.5% versus 2.5% (P=0.60). Complication rates were also similar in the obese and non-obese groups: bladder injury, 2.5% versus 5.4% (P=0.77); laparoconversion, 5.1% versus 4.5% (P=0.77). Rates of reoperation (excluding women with de novo urinary stress incontinence) were 12.8% in the obese group and 8.1% in the non-obese group (P=0.58).

CONCLUSION

Laparoscopic sacrocolpopexy has similar complication rates and short-term outcomes among both obese and non-obese women.

Urinary incontinence, fecal incontinence and pelvic organ prolapse in a population-based, racially diverse cohort: prevalence and risk factors

OBJECTIVES

: We investigated the prevalence of and risk factors for combinations of urinary incontinence (UI), fecal incontinence (FI) and pelvic organ prolapse (POP) in racially diverse women older than 40 years.

METHODS

: The Reproductive Risks for Incontinence Study at Kaiser is a population-based study with data from 2106 women older than 40 years. Pelvic floor conditions were determined by self-report. Risk factors were assessed by self-report, interview and record review. Independent risk factors were identified by multinomial logistic regression analysis.

RESULTS

: At least one pelvic floor condition was reported by 714 (34%) women. Of these, 494 (69%) had only UI, 60 (8%) only POP, and 46 (6%) only FI. Both UI and FI were reported by 64 (9%) and both UI and POP by 51 (7%). Among women with FI, 60% reported more than one condition. Corresponding figures for POP and UI were 49% and 18%. Estrogen use and constipation were shared risk factors for UI, FI and POP. Body mass index was a unique risk factor UI only, diabetes FI only and parity POP only. No clear pattern could be found to support the hypothesis that risk factors for single conditions are more strongly associated with combined conditions.

CONCLUSIONS

: Patients with FI or POP often have concomitant UI. These diseases both share and have unique risk factors in a complex pattern.

Faecal incontinence in the elderly: issues and interventions in the home

This paper discusses current evidence-based guidelines for the management of faecal incontinence in the elderly. The key aspects of maintaining dignity, quality of life and self-esteem are addressed within a presentation of good assessment, prevention, management and treatment principles. Particular focus is given to the added problems that faecal incontinence may bring to the elderly person suffering with this debilitating, and often embarrassing condition. The increased risk to skin integrity is discussed, with reference to available guidance to help nurses manage the risk of skin breakdown associated with persistent faecal incontinence.

Segmentation of female pelvic cavity in axial T2-weighted MR images towards the 3D reconstruction

The anatomies of pelvic structures are critical for the diagnosis of pelvic floor dysfunctions. However, because of the complex background, the imaging appearances of pelvic organs and muscles are frequently distorted by noise and partial volume effect. Magnetic resonance imaging with its clear imaging quality of the female pelvic cavity is preferred for many studies. As such, correct segmentations of the pelvic structures on MR images are required for accurate diagnoses. Effective algorithms for axial T2-weighted MR images have been proposed, which are based on the imaging features of different structures and various image clues. In this paper, we review these algorithms and evaluate their performance, and discuss implementation issues and aspects towards constructing the three-dimensional models.

[Obesity and urogynecology: a systematic review]

OBJECTIVES

To determine the specificity of the management of urogynecologic disorders in obese women.

PATIENTS AND METHODS

REVIEW OF THE LITERATURE

obesity, genital prolapse, pelvic organ prolapse, urinary incontinence, anal incontinence.

RESULTS

The relative risk of urinary incontinence (UI) for morbidly obese women (BMI>40 kg/m(2)) is five times greater than a normal weight woman. A 10% weight loss reduced the frequency of urinary leakage by 50%. Beyond a BMI of 35 kg/m(2), the success rate of suburethral sling decreased to 50% with an increased risk of de novo urgenturies. Within this population of morbidly obese women, bariatric surgery was as successful as or more than surgery for incontinence. Patients with morbid obesity are three times as likely to experience anal incontinence, with a prevalence reaching 32%. The treatment of anal incontinence in obese patients is not clearly codified. The association between obesity and prolapse is very controversial according to the methodology used in the studies. Treatment of genital prolapse in obese women is little studied in the literature. Only sacrocolpopexy by laparotomy was studied. No more complications were found in this population.

CONCLUSION

Now we have specific data concerning urogynecology in obese women to better manage these patients.

The effect of concealed concomitant anal incontinence symptoms in patients with urinary incontinence on their quality of life

INTRODUCTION AND HYPOTHESIS

We evaluated the bother of concomitant anal incontinence (AI) in women with urinary incontinence (UI) who do not primarily report their anal symptoms.

METHODS

This prospective study assessed patients with complaings of primary UI without initially reporting anal symptoms. After urogynecological assessment, all patients were asked to complete the validated versions of the Urogenital Distress Inventory (UDI-6), Incontinence Impact Questionnaire (IIQ-7), Pelvic Floor and Incontinence Sexual Impact Questionnaire (PISQ-12), Wexner Incontinence Scale (WIS) score, and Beck Anxiety Inventory (BAI). Patients who scored nil in the WIS constituted the group of only UI, and patients with scores ≥1 were grouped as double incontinence (DI)., and the groups were compared.

RESULTS

Among 136 women, 69.1 % (94) had only UI, whereas 30.9 % (42) had DI. There were no differences in age, parity, body mass index (BMI), and prolapse status between patients with UI and those with DI, except menopausal status. Women with DI scored worse for IIQ-7, PISQ-12, and BAI questionnaires compared with women with UI. This difference was not statistically significant for IIQ-7 only.

CONCLUSIONS

Our data show that concealed AI symptoms may contribute to the anxiety of the patient and even alter the perception of urinary symptoms. Actually, a significant number of women suffer from DI without reporting their anal symptoms, which results in underdiagnosing of concomitant AI. To prevent the suboptimal management of patients with lower urinary tract symptoms, standardized questionnaires for AI should be included in the evaluation of all patients with lower urinary tract symptoms.

Radiofrequency treatment for fecal incontinence: is it effective long-term?

OBJECTIVE

The aim of this study was to evaluate the short- and long-term outcome of the radiofrequency treatment for moderate to severe fecal incontinence.

DESIGN

This study is a retrospective review of a single-institution experience.

PATIENTS

Patients who underwent the radiofrequency procedure were included.

MAIN OUTCOME MEASURES

The primary outcomes measured were the complication rate, short- and long-term response, and the rate of subsequent intervention for incontinence.

RESULTS

Twenty-seven patients underwent 31 radiofrequency procedures (81% women; mean age, 64 years). Median length of symptoms was 3 years. Biofeedback had failed for 52% of patients, and 23% of patients had previous surgical intervention. Thirty-eight percent of patients had a sphincter defect. Minor complications were observed in 19% of the patients. A treatment response was noted in 78% of the patients (mean Cleveland Clinic Florida Fecal Incontinence Score: 16 (baseline) and 10.9 (3 months postoperatively)). However, a sustained long-term response without any additional intervention was noted in 22% of the patients, and 52% of the patients underwent or are awaiting additional intervention for persistent or recurrent incontinence (mean follow-up, 40 months).

LIMITATION

This study is limited by its retrospective nature and the limited number of subjects.

CONCLUSIONS

The radiofrequency procedure was safe, but a long-term benefit was noted in a minority of patients with moderate to severe fecal incontinence. Additional interventions were required in more than half of the patients. Larger studies are needed to determine the impact of various patient-related factors on the outcome of the radiofrequency treatment to identify the ideal patient for this therapy.

[Results of sacral neuromodulation on the urinary and fecal incontinence and sexuality in 20 women suffering from a double incontinence]

CONTEXT

Urinary and faecal incontinence (defining double incontinence) are common conditions, which are frequently associated and can altered sexuality. The effectiveness of the sacral nerve modulation (NMS) in the treatment of the urge urinary incontinence, faecal incontinence and double incontinence was shown.

OBJECTIVE

The present article aims to determine the impact of SNM on female sexual function in twenty women suffering from a double incontinence.

METHODS

All patients who received sacral neuromodulation for urge urinary and/or faecal incontinence between 2005 and 2010 and who still had the implant were included. Only 20 sexually active patients suffering from double incontinence were considered eligible. They completed a questionnaire on follow-up examinations.

RESULTS

The initial indication of NMS was the urge urinary incontinence for 15 patients and the faecal incontinence for five patients. Ten patients (50%) were improved on two incontinence. All patients preserved sexual activity after the treatment of NMS. NMS improves the quality of sexual activity in 45% patients. The numbers of urinary and faecal episodes of incontinence are decreased respectively for 50% and 15% patients during sexual activity. The quality of sexual's life and orgasm score are significantly increased in the group of patients improved on the DI.

CONCLUSION

This study confirms the effectiveness of NMS in the treatment of double incontinence which half patients are improved on the two incontinence. This study shows that improvement of urinary or faecal incontinence could have a positive impact on sexuality of these patients, especially for patients improved double incontinence. It is difficult to know if these results are related to its direct action on the neurological ways of sexual function or on its benefit on the continence.

Prevalence of and quality of life related to anal incontinence in women with urinary incontinence and pelvic organ prolapse

OBJECTIVE

To investigate the prevalence of anal incontinence (AI) in woman with urinary incontinence (UI) and pelvic organ prolapse (POP). We also evaluated the impact on quality of life (QoL).

STUDY DESIGN

One hundred and ninety patients with UI or POP and 73 controls were recruited. AI was investigated by the Wexner index and the prevalence rates were obtained in all groups. Patients with AI completed the Fecal Incontinence Quality of Life questionnaire (FIQL). QoL was assessed using the Medical Outcome Study 36-item Short Form Health Survey (SF-36).

RESULTS

AI prevalence was 40.54% in the UI group and 27.91% in the POP group (p<0.0001). In the UI and POP groups correlations were found between the Wexner score and the domains of the FIQL and SF36.

CONCLUSION

The UI group had higher prevalence of AI than the other groups. The AI adversely affected the QoL of patients.

Prevalence and predictive factors of fecal incontinence

Background/Aims

Most previous epidemiologic studies about fecal incontinence were performed in specific populations in Korea. We aimed to estimate the prevalence and predictive factors of fecal incontinence in adult Korean population, both men and women aged 20 years and over.

Methods

Subjects who had undergone medical check-up for health screening were enrolled. They completed the structured questionnaires, including demographics, gastrointestinal symptoms, medical and social histories, and also about their bowel habits. Logistic regression models were constructed to identify the predictive factors for having fecal incontinence.

Results

Among the total of 1,149 subjects (mean age, 44.8 ± 10.2 years; 648 males), the overall prevalence of fecal incontinence was 6.4%, while the older group (> 50 years old) showed the higher prevalence than the younger group (≤ 50 years old) (10.4% vs 4.9%, P = 0.001) without gender difference. Most patients had mild fecal incontinence in 78.4%. By multivariate analysis, old ages (Odd ratio [OR], 3.1; 95% confidence interval [CI], 1.9-5.2; P < 0.001), watery stool (OR, 2.8; 95% CI, 1.5-4.9; P = 0.001) and functional diarrhea (OR, 2.7; 95% CI, 1.4-5.4; P = 0.004) were found to be independent predictors for fecal incontinence.

Conclusions

The prevalence of fecal incontinence in Korean adults was 6.4%, and it was significantly more prevalent in older people without any gender difference. Aging and diarrhea were independent predictive factors of fecal incontinence. Therefore, proper control of the bowel pattern would lead to the prevention of fecal incontinence.

Prevalence of fecal incontinence and its relationship with urinary incontinence in women living in the community

OBJECTIVE

The aim of this study was to document the age-specific prevalence of fecal incontinence (FI), as well as its relationship to childbirth and urinary incontinence (UI), in a community-based sample of Australian women.

METHODS

A total of 444 women aged 26 to 82 years, originally recruited from a community-based research database, completed a self-administered study questionnaire. Prevalence of FI was assessed using the Pelvic Floor Distress Inventory, and UI and its subtypes were determined using the Questionnaire for Urinary Incontinence Diagnosis. Univariate (Pearson's χ tests) and multivariate logistic regression analyses were used to assess the relationship between FI type and UI adjusting for age and body mass index (BMI).

RESULTS

Data were analyzed for 442 women. The overall prevalence of any FI was 20.7% (95% CI, 16.9%-24.5%). Loose FI was reported by 91 of 442 women, yielding a prevalence of 20.7% (95% CI, 16.9%-24.5%). Well-formed FI was reported by 20 of 442 women, yielding a prevalence of 4.5% (95% CI, 2.6%-6.4%). All the women with well-formed FI also reported problems of loose FI. The prevalence of FI increased with age up to 75 years for both types of FI. FI was not related to parity (P = 0.9). The highest proportion of any FI (24.4%) occurred in women with a parity of four or greater; however, 20.3% of nulliparous women reported FI. Within parous women, there was no significant association found between FI and history of self-reported instrumental delivery (P = 0.4). About two thirds of the women with loose and well-formed FI also reported coexisting UI. Loose FI was significantly associated with any UI (odds ratio, 2.8; 95% CI, 1.7-4.8) after adjusting for age and BMI (P < 0.001). Well-formed FI was not significantly associated with any UI after adjusting for age and BMI.

CONCLUSIONS

FI is a common condition affecting one in five adult women in the community. In our study, women with loose FI, but not well-formed FI, were more likely to have UI independent of their age and BMI. Being parous was not associated with an increased risk of any FI.

Using behavioural methods to manage faecal incontinence

Faecal incontinence is a common problem for patients who have suffered a stroke. However, patients arriving at a neurorehabilitation unit are often reluctant to disclose their problem, and transfer documentation is sometimes incomplete. Nurses need to be aware that this is a sensitive area for patients, which can adversely affect their rehabilitation progress. Nurses and other professional practitioners must work together as a team, as the impact of faecal incontinence can be highly distressing for patients, and can result in inefficient use of therapy time. This article examines how the rehabilitation nurse, using evidence-based practice, can manage faecal incontinence effectively within a structured assessment and therapy programme, and shows it is possible to manage patients' bowel actions proactively. The benefits of this include maximizing therapy and nursing time and preventing delayed discharges. This article is based on a thorough assessment originating from a case study.

Fecal incontinence: prevalence, severity, and quality of life data from an outpatient gastroenterology practice

Background. The prevalence of fecal incontinence varies tremendously as a result of inadequate data collection methods. Few office-based studies have assessed the prevalence of fecal incontinence and none have looked at modifiable risk factors or effect on quality of life. Design, Settings, Patients, and Main Outcome Measures. Five hundred patients who visited our inner city, university-based gastroenterology practice, were asked about symptoms of fecal incontinence. We also retrospectively reviewed 500 charts to identify the frequency of patient-physician reporting of fecal incontinence. Results. Of the 500 patients that were directly questioned, 58 (12%, 43 women, 15 men) admitted to fecal incontinence compared to 12 (2.4%) in the retrospective arm. Patients with fecal incontinence and loose/watery stool reported the lowest quality of life scores. While the average severity score was similar between men and women, women had a significantly lower average quality of life score (3.04 versus 2.51; P < 0.03). Conclusions. The identification of fecal incontinence increases when patients are directly questioned. Identifying and treating patients with loose stool is a potential strategy to improve quality of life in this patient population. In men and women with similar severity of fecal incontinence, women have a significantly lower quality of life.

Menopause and obstetric history as risk factors for fecal incontinence in women

BACKGROUND

Fecal incontinence is a highly prevalent condition, especially in women. However, few data on prevalence in women attending primary care are available, particularly regarding the presence of risk factors.

OBJECTIVE

The aim of this study was to determine characteristics of women with fecal incontinence and to analyze obstetric history and menopause as potential risk factors.

DESIGN

Observational study with a cross-sectional design.

SETTINGS

Patients in primary care at 10 health care centers in Barcelona, Spain.

MAIN OUTCOME MEASURES

Fecal incontinence was defined as loss of flatus or liquid/solid stool occurring at least monthly. Data on the following variables were collected by face-to-face interviews and patient questionnaires: demographic and clinical characteristics, obstetric history, menopause data, fecal incontinence, and quality of life. Univariable and multivariable analyses were performed to study the association of potential risk factors with fecal incontinence.

RESULTS

The study included 332 women with a mean age of 60.8 (SD, 17.8) years. The prevalence of fecal incontinence was 12.0% (40/332). Flatus incontinence was reported in 27 patients (67.5%), liquid stool incontinence in 25 (62.5%), and solid stool incontinence in (19) 47.5%. On multivariable analysis, the only independent risk factors for fecal incontinence were an obstetric history of complicated deliveries (instrumentation or podalic presentation; OR, 3.66; 95% CI, 1.54-8.68, P = .003) and menopause (OR, 5.67; 95% CI, 1.35-23.78; P = .018).

LIMITATIONS

The cross-sectional design hampered identification of the time at which the impact of menopausal status occurred, and data obtained from patient interviews was subject to recall bias.

CONCLUSIONS

Complicated deliveries are risk factors for fecal incontinence in women. Fecal incontinence appears to be more prevalent in menopausal women.

Sacral nerve stimulation increases activation of the primary somatosensory cortex by anal canal stimulation in an experimental model

BACKGROUND

Sacral and posterior tibial nerve stimulation may be used to treat faecal incontinence; however, the mechanism of action is unknown. The aim of this study was to establish whether sensory activation of the cerebral cortex by anal canal stimulation was increased by peripheral neuromodulation.

METHODS

A multielectrode array was positioned over the right primary somatosensory cortex of anaesthetized rats. A brief burst of electrical stimulation was applied to either the left sacral root or the left posterior tibial nerve, and evoked potentials from anal canal stimulation were signal-averaged at intervals over 1 h. At the end of the experiment, the cerebral cortex was removed and probed for polysialylated neural cell adhesion molecule (PSA-NCAM).

RESULTS

Sacral nerve root and posterior tibial nerve stimulation significantly increased the peak amplitude of primary cortical evoked potentials by 54.0 and 45.1 per cent respectively. This change persisted throughout the period of observation. The density of PSA-NCAM-positive cells in the somatosensory cortex underlying the electrode array was increased by approximately 50 per cent in the sacral nerve-stimulated group.

CONCLUSION

Brief sacral neuromodulation induces profound changes in anal canal representation on the primary somatosensory cortex, providing a plausible hypothesis concerning the mechanism of action of neuromodulation in the treatment of faecal incontinence.

Impact of high-level sport practice on anal incontinence in a healthy young female population

BACKGROUND

Regular physical activity usually confers health benefits, but high-level sport may induce harmful outcomes, such as pelvic floor dysfunction. Urinary incontinence (UI) was previously documented, but few data are available about anal incontinence (AI) in female athletes. Our aim was to determine the role of high-level sport practice on AI in a young, healthy female population.

METHODS

In this cross-sectional study, we included women aged 18-40 years. Self-administered questionnaires were delivered to each female volunteer. Two groups were defined: (1) intensive sport (IS) group: high-level sport (>8 hours weekly), and (2) nonintensive sport (NIS) group: all other subjects.

RESULTS

Of the 393 women enrolled, 169 were in the IS group and 224 were in the NIS group. Women of the IS group were significantly younger than the others (21.74±4.28 vs. 24.87±5.61 years, p<0.001) and had less births (0.07±0.31 vs. 0.20±0.62, p=0.005). The prevalence of AI was statistically higher in the IS group than in the NIS group (14.8% vs. 4.9%, p=0.001), as was UI (33.1% vs. 18.3%, p=0.001). Multivariate analysis showed that IS practice (odds ratio [OR] 2.99, 95% confidence interval [CI] 1.29-6.87, p=0.010) and body mass index (BMI) (OR 1.14, 95% CI 1.01-1.28, p=0.033) were significantly linked to AI when taking into account major confounding factors (age and births). In the IS group, AI was mainly represented by loss of flatus in 84%.

CONCLUSIONS

High-level sport appears to be a significant independent risk factor for AI in healthy young women. These results suggest that preventive measures, such as pelvic floor muscle training, may be proposed for this young population.

Modified dynamic gracilis neosphincter for fecal incontinence: an analysis of functional outcome at a single institution

BACKGROUND

We undertook a prospective longitudinal study of patients with end-stage fecal incontinence who were undergoing transposition of the gracilis muscle as a neo-anal sphincter with external low-frequency electrical stimulation of the nerve to the gracilis combined with biofeedback.

METHODS

A total of 31 patients (21 male, 10 female: median age: 22 years; range: 4-77 years) underwent this procedure for treatment of traumatic disruption (11 patients, 35%), congenital atresia (11 patients, 35%), iatrogenic injury (6-20%), and perineal sepsis (3 patients, 10%). The gracilis muscle was transposed at operation in an alpha or gamma configuration. Low-frequency (7 Hz) transcutaneous electrical stimulation commenced 2 weeks after operation and was continued for up to 12 weeks. Biofeedback therapy, which consisted of supervised neosphincter squeeze exercises, commenced simultaneously and continued for up to 28 weeks. Outcome was assessed by clinical examination, anal manometry, the Cleveland Clinic Florida continence score (CCFS), and the Rockwood quality of life scale (FIQL). Successful outcome was defined by improvement in clinical outcome, patient satisfaction, a positive result on anal manometry, and/or CCFS < 9, or FIQL > or = 4.

RESULTS

At median follow-up of 67 months, overall improvement was seen in 22 (71%). Maximum resting pressure (MRP) and maximum squeeze pressure (MSP) improved significantly after operation [MRP pre versus post, mean (SD), cm water-13.8 (9.6) versus 20.9 (11.3); P = 0.01; and MSP 36.6 (22.4) versus 95.4 (71.2), P = 0.001]. In a subset of 18 patients who showed improvement after operation, the CCFS score (mean, SD) improved from 19.2 (3.4) to 5.2 (5.6); P = 0.0001. FIQL (mean, SD) showed significant improvement in all four domains in 14 patients who reported improvement since the year 2000.

CONCLUSIONS

A modified dynamic gracilis neoanal sphincter for end-stage fecal incontinence helps restore and sustain continence with improvement in quality of life in the majority of patients. The procedure was most effective as augmentation in those who had suffered a traumatic injury, when compared with patients with congenital atresia and sepsis that had resulted in loss of the native anal sphincter.

Transvaginal three-dimensional ultrasound: a method of studying anal anatomy and function

OBJECTIVES

To explore the possibility of using transvaginal 3D ultrasound as a method of assessing the compartments of the anal canal during rest, to determine the effect of squeeze, and to compare these findings with those obtained using the endoanal technique in the same women.

METHODS

Transvaginal 3D ultrasound was used in a cross-sectional study measuring the anal mucosa and sphincters during rest and squeeze in 20 nulligravida women, comparing the results with those of endoanal measurements. Measurements were also performed of the anal mucosa, anorectal curvature (ARC), and anovaginal angle (AVA) and distance (AVD).

RESULTS

Volume measurements of the anal mucosa were only possible using transvaginal ultrasound. The mean volume of the anal canal using the transvaginal technique was 7.93 (SD 2.26) and 7.34 (1.54) cm(3) during rest and squeeze, respectively (P = 0.082). The ARC became more acute (3.46 vs. 4.12°/mm, P = 0.031) during squeeze and AVA increased (31.7° vs. 35.8°, P = 0.010). The volume of the anal mucosa (3.12 cm(3)) did not change (P = 0.193), but was distorted during squeeze at the level of the puborectalis sling (P < 0.001 for upper cross-section and diameter). The anal canal was 1 cm longer (P < 0.001), the IAS volume larger (2.97 and 2.08 cm(3), P = 0.003), and the EAS volume smaller (1.85 and 3.96 cm(3), P < 0.001) using the 3D transvaginal technique compared with the endoanal measurements at rest, with similar differences observed on squeeze.

CONCLUSION

In contrast to the endoanal method, transvaginal 3D ultrasound provides a complete assessment of the anal canal, including the mucosa. This method seems suitable for functional studies such as in the present one, which shows that voluntary squeeze increases the angulation of the anal canal and distorts the bowel cross-section at the level of the puborectal muscle.

Association between bowel symptoms, symptom severity, and quality of life in Swedish patients with fecal incontinence

OBJECTIVES

The association between abdominal symptoms, disease severity of fecal incontinence (FI), and quality of life (QoL) is not yet clear. We hypothesized that it would become clearer by prospective diary data. We also aimed to compare QoL of FI patients with ulcerative colitis (UC) patients in relapse and remission.

MATERIAL AND METHODS

Sixty-five consecutive female patients with FI recorded bowel symptoms prospectively on diary cards. QoL was evaluated with the disease specific short health scale questionnaire (SHS). Patients with UC in remission and relapse were used as a reference group regarding SHS.

RESULTS

FI patients had median 3.5 leakage episodes/week. In all, 48% of bowel movements were associated with urgency. Urgency was correlated to decreased QoL according to SHS domains: symptoms (Rho = 0.54, p = 0.0002), function (Rho = 0.48, p = 0.0008), and disease related worry (Rho = 0.32, p = 0.027). Abdominal pain and bloating, reported by nearly half of patients, correlated to deceased QoL but not to number of leakages. QoL of patients with FI compared to UC in active phase (n = 35) was similar. FI patients had decreased QoL compared to UC in remission (n = 94) in all dimensions of SHS: symptoms (p < 0.0001), function (p < 0.0001), disease related worry (p < 0.0001), and general well being (p = 0.03).

CONCLUSION

Urgency and irritable bowel syndrome (IBS)-like symptoms were associated with decreased QoL in FI. Therefore, IBS should be considered as an important confounding factor in FI QoL studies. QoL in patients with FI was considerably decreased, in a similar extent as in patients with UC in relapse.

Influence of perineal prostatectomy on anal continence

OBJECTIVE

Perineal prostatectomy has been proposed as a less invasive and safe procedure, but the risk of anal incontinence has been studied. This study aimed to evaluate the effects of perineal access on anal continence mechanisms after perineal prostatectomy.

METHODS

From August 2008 to May 2009, twenty three patients underwent perineal prostatectomy. These patients were evaluated before surgery and eight months postoperatively using the Cleveland Clinic Anal Incontinence Score, the Fecal Incontinence Quality of Life Score, and anorectal manometry.

RESULTS

The mean age of the subjects was 65 (range, 54-72) years, and the mean prostate weight was 34.5 (range, 24-54) grams. Gleason scores ranged from 6-7, and the mean Cleveland Clinic Anal Incontinence Score (mean±standard deviation) values were 0.9±1.9 and 0.7±1.2 (p>0.05) before and after surgery, respectively. The Fecal Incontinence Quality of Life Score did not change significantly after surgery. The mean values for anal manometric parameters before and after surgery were, respectively: Resting Pressures of 64±23 mmHg and 65±17 mmHg (p = 0.763), Maximum Squeezing Pressures of 130±41 mmHg and 117±40 mmHg (p = 0.259), High Pressure Zones of 3.0±0.9 cm and 2.7±0.8 cm(p = 0.398), Rectal Sensory Thresholds of 76±25 ml and 71±35 ml (p = 0.539), Maximum Tolerated Rectal Volumes of 157±48 ml and 156±56ml (p = 0.836), and Sphincter Asymmetry Indexes 22.4±9% and 14.4±5% (p = 0.003).

CONCLUSION

There was a significant decrease in the sphincter symmetry index after perineal prostatectomy. With the exception of the sphincter asymmetry index, perineal prostatectomy did not affect anal continence parameters.

An Open-Label, Noncomparative, Multicenter Study to Evaluate Efficacy and Safety of NASHA/Dx Gel as a Bulking Agent for the Treatment of Fecal Incontinence

Fecal incontinence (FI) is the involuntary loss of rectal contents through the anal canal. Reports of its prevalence vary from 1–21%. Studies, have demonstrated a positive effect on FI symptoms with injectable bulking agents. This study evaluated the safety and efficacy of NASHA/Dx gel in the treatment of FI. One hundred fifteen eligible patients suffering from FI received 4 injections of 1 mL NASHA/Dx gel. Primary efficacy was based on data from 86 patients that completed the study. This study demonstrated a ≥50% reduction from baseline in the number of FI episodes in 57.1% of patients at 6 months, and 64.0% at 12 months. Significant improvements (P < .001) were also noted in total number of both solid and loose FI episodes, FI free days, CCFIS, and FIQL scores in all 4 domains. The majority of the treatment related AEs (94.9%) were mild or moderate intensity, and (98.7%) of AEs resolved spontaneously, or following treatment, without sequelae. Results of this study indicate NASHA/Dx gel was efficacious in the treatment of FI. Treatment effect was significant both in reduction of number of FI episodes and disease specific quality of life at 6 months and lasted up to 12 months after treatment.

Using the Brink score to predict postpartum anal incontinence

OBJECTIVE

To evaluate whether antepartum pelvic floor muscle strength, as measured by the Brink scale, predicts postpartum anal incontinence.

STUDY DESIGN

This prospective cohort study of primigravid women used validated questionnaires and standardized pelvic examinations to evaluate subjects during the third trimester and at 2 postpartum time points.

RESULTS

Of the initial 129 subjects, 102 and 81 completed 2 week and 6 month postpartum visits. 35% had cesarean deliveries. The antepartum prevalence of fecal incontinence (14%) did not differ significantly from the postpartum (17% at 2 weeks, 11% at 6 months). However, the prevalence of flatal incontinence fell from antepartum (65%) to postpartum (47% at 2 weeks, P = .001; 49% at 6 months, P = .012). Mean Brink score decreased postpartum; no correlations were found between Brink score and questionnaire scores.

CONCLUSION

Anal incontinence symptoms are common in the third trimester of a first pregnancy and may regress or resolve after delivery. Brink score did not predict postpartum anal incontinence.