Community-based prevalence of anal incontinence

The functional and psychosocial impact of fecal incontinence on women with urinary incontinence

OBJECTIVES

The study was undertaken to determine the impact of fecal incontinence (FI) on functional status and quality of life in women with urinary incontinence (UI).

STUDY DESIGN

In 24 months 732 women completed a standardized assessment and questionnaire, including the Short Form (SF)-12 and Incontinence Quality of Life (I-QOL) scores. Analysis of variance was used to compare SF-12 scores between groups defined as having UI, FI, or both UI and FI. I-QOL scores in patients with UI or UI and FI were compared by using the Student t test.

RESULTS

Of the 732 patients enrolled, 425 patients had either UI (n = 342, 80%), FI (n = 18, 4%), or both (n = 65, 15%). Greater impairment in physical functioning was seen in the group with UI and FI (38.6; P =.027) compared with the group with UI (42.4). Significant decreases in I-QOL scores were seen for the group with UI and FI compared with those with UI (P <.005).

CONCLUSION

Fecal incontinence further reduces the functional status and quality of life of women with urinary incontinence.

Systematic review of dynamic graciloplasty in the treatment of faecal incontinence

Background

The aim of this systematic review was to compare the safety and efficacy of dynamic graciloplasty with colostomy for the treatment of faecal incontinence.

Methods

Two search strategies were devised to retrieve literature from the Medline, Current Contents, Embase and Cochrane Library databases up until November 1999. Inclusion of papers depended on a predetermined protocol, independent assessments by two reviewers and a final consensus decision. English language papers were selected. Acceptable study designs included randomized controlled trials, controlled clinical trials and case series. Forty papers met the inclusion criteria. They were tabulated and critically appraised in terms of methodology and design, outcomes, and the possible influence of bias, confounding and chance.

Results

No high-level evidence was available and there were no comparative studies. Mortality rates were around 2 per cent for both graciloplasty and colostomy. Morbidity rates reported for graciloplasty appear to be higher than those for colostomy. Dynamic graciloplasty was clearly effective at restoring continence in between 42 and 85 per cent of patients, whereas colostomy is, by its design, incapable of restoring continence. However, dynamic graciloplasty is associated with a significant risk of reoperation.

Conclusion

While dynamic graciloplasty appears to be associated with a higher rate of complications than colostomy, it is clearly a superior intervention for restoring continence in some patients. It is recommended that a comparative, but non-randomized, study be undertaken to evaluate the safety of dynamic graciloplasty in comparison to colostomy, and that the procedure should be performed only in centres where it is carried out routinely.

[Surgical treatment of anal incontinence]

Surgery is mandatory for fecal incontinence when medical treatments and reeducation by biofeedback are ineffective. Sphincter disruption is the most frequent cause. Sphincter repair with or without overlapping is indicated in the large majority of cases. Short-term results are good but result is not ever maintained with time. In case of failure, or when the defect concerns more than 180 degrees, it is necessary to use a substitutive technique. Artificial anal sphincter is often first proposed because of its apparent technical simplicity and because it is cheaper than dynamic graciloplasty. Results are excellent. Failures are due to local infection or device disfunction. Dynamic graciloplastie may be proposed in patients with severe perineal lesions, or failure of the other methods. Its results are also excellent, except for the patients having disordered rectal perception. Sacral nerve stimulation is limited to patients with idiopathic or neurologic incontinence. Because definitive implantation is done only following positive preoperative stimulation test, short-term results are very good.

[Sphincteric function quantification by measuring the capacity to sustain the squeeze pressure of the anal canal]

BACKGROUND

It has been demonstrated that the maximum squeeze pressure and the mean resting pressure do not reflect the true clinical situation of patients having fecal incontinence, as well as the functional status of the anal canal. Furthermore, a wrong diagnosis could be obtained and therefore misleading to a not effective treatment.

AIM

Under the hypothesis that squeezing and sustaining the anal canal contraction is more important than the maximum squeeze pressure, the capacity to sustain the squeeze pressure of the anal canal was analyzed aiming to quantify the sphincteric function.

METHODS

Seventy-two patients having fecal incontinence in different degrees (56 female) and 15 normal individuals (9 female) were submitted to anorectal manometry to measure the mean resting pressure, the maximum voluntary squeeze pressure and the capacity to sustain the squeeze pressure.

RESULTS

Normal individuals had normal values of mean resting pressure and maximum squeeze pressure, and adequate capacity to sustain the squeeze pressure of the canal anal. Incontinent patients had mean resting pressure and maximum squeeze pressure with normal or below normal pressoric values and similar profile of capacity to sustain which was moderate in the initial phase and worse in the intermediate and final phases, with decreasing of the capacity to sustain more than 35% in 78% of the patients. The maximum squeeze pressure presented excellent specificity (100%), but low sensitivity (46%) for fecal incontinence. Comparatively, the squeeze pressure presented high specificity (93%) and high sensitivity (78%) for fecal incontinence. Although the maximum squeeze pressure did not indicate false positive, it presented a 72% false negative. The probability of this event to happen with the capacity to sustain measure is 20% lower, and it was statistically significant.

CONCLUSION

Sphincteric function can be better analyzed by using the capacity to sustain the squeeze pressure. capacity to sustain indicates more precisely the functional capacity of the anal canal in relation to voluntary continence, and it is better than maximum squeeze pressure as an isolated index.

Risk Factors for Hospital-Acquired Incontinence in Elderly Female Hip Fracture Patients

BACKGROUND

The objective of this study was to estimate the incidence of, and identify risk factors for, incontinence in female hip fracture patients. The study was a secondary analysis of data abstracted from medical records in hospitals in Pennsylvania, Texas, New Jersey, and Virginia.

METHODS

The study included women aged 60 years and older who were admitted to one of the study hospitals with hip fracture. Measurements included incontinence at discharge as recorded in the medical records, demographic information, cognitive and functional status, and two measures of severity of illness (Charlson Comorbidity Index and Sickness at Admission Scale score).

RESULTS

Data from 6516 women were analyzed. Twenty-one percent (n = 1365) became incontinent during hospitalization. After adjusting for confounders (i.e., age, race, malnutrition, comorbidity, and severity of illness), admission from a nursing home or other long-term care facility (odds ratio [OR] 1.68, 95% confidence interval [CI] 1.29-2.19), confusion (OR 3.44, 95% CI 2.79-4.24), use of a wheelchair or device for walking (OR 1.53, 95% CI 1.29-1.83), and prefracture dependence on others for ambulation (OR 2.51, 95% CI 1.64-3.85) significantly increased the odds of developing incontinence during hospitalization.

CONCLUSION

Hospital-acquired incontinence affects 21% of female hip fracture patients. Certain easily identifiable patient characteristics place female hip fracture patients at high risk. Interventions to increase staff awareness of this vulnerable population need to be tested to minimize the incidence of hospital-acquired incontinence.

Vitamin B(12) deficiency and incontinence: is there an association?

BACKGROUND

This study investigated the relationship between B(12) (cobalamin) levels and incontinence in older outpatients using secondary data analysis.

METHODS

Between 1991 and 1999, there were 929 patients (258 men and 671 women) for whom urinary incontinence (UI), fecal incontinence (FI), and B(12) were prospectively recorded. Covariates included race, gender, age, medications, Mini-Mental State Examination, modified illness rating, and instrumental activities of daily living (IADLs).

RESULTS

Some form of incontinence (UI or FI or both) was found in 41% of subjects, isolated UI in 34%, double incontinence (DI) in 12%, and isolated FI in 4%. Having UI increased the risk of also having FI (p <.0001). Serum B(12) levels of 300 pg/ml or less were not predictive of isolated UI or isolated FI. However, in logistic regression, DI was predicted by B(12) (odds ratio [OR] = 2.113, p =.0094), IADLs (OR = 0.810, p <.0001), cathartics/laxative use (OR = 1.902, p =.126), and diuretic use (OR = 2.226, p =.006). Considering isolated UI in women, higher IADLs reduced risk of UI (OR = 0.956, p =.002), while diuretics (OR = 1.481, p =.041) and antihistamines (OR = 1.909, p =.046) both increased risk of UI. In men, only use of anticonvulsant medications (OR = 4.529, p =.023) increased risk of isolated UI. Greater physical illness in both genders increased risk of isolated FI (OR = 1.204, p =.006).

CONCLUSIONS

These findings suggest that serum B(12) at levels of 300 pg/ml or less are not associated with isolated UI or isolated FI but may play a role in DI. A possible association of low B(12) levels with DI is intriguing because of the implications for treatment and prevention. More immediately, medication side effects should be considered when evaluating this problem.

[Pudendal neuropathy: correlation with demographic data, severity index and pressoric parameters in patients with fecal incontinence]

BACKGROUND

Fecal incontinence stands for inability in maintaining the control of defecation to a socially acceptable and adequate time and place, resulting in unwanted release of gas, liquid or solid stool. The diagnosis needs multiple exams. Anorectal manometry is mandatory for this study. The correlation between manometry with electophysiological studies and symptoms is not yet clear in the literature.

AIMS

Correlate values of anal manometry, pudental nerve terminal motor latency and co morbidity in fecal incontinence patients.

METHODOLOGY AND PATIENTS

Patients with clinical fecal incontinence, who attended the outpatient department of "Hospital Nossa Senhora da Concei o", Porto Alegre, RS, Brazil, between March 1997 and June 2000, were studied prospectively. Every single patient has undergone a general investigation, incontinence score, anal manometry, bilateral pudendal nerve terminal motor latency and physical examination. For statistical purposes the patients were separated in groups according to the results of the anal manometry, pudendal neuropathy, for age and sex.

RESULTS/CONCLUSION

Thirty-nine patients were studied, 85,6% female, average age 60,1 years (+/- 12,89). The average index of the fecal incontinence was of 9,30 (+/- 4,93). In the anorectal manometry 23 patients showed low pressure. The pressures were significantly higher among males. The nerve terminal motor latency and pudental nerve (neuropathy) time was greater in 14 patients (35,9%). The age and the time of pudental nerve terminal motor were significantly co related. The other co relations were not statistically significant.

Medium-term results of permanent sacral nerve stimulation for faecal incontinence

BACKGROUND

Anal sphincter surgery for faecal incontinence is associated with significant morbidity and a variable outcome. Sacral nerve stimulation may provide a good functional outcome with minimal morbidity. This paper reports the experience in a single centre over 5 years.

METHODS

Fifteen consecutive patients (14 women), median age 60 (range 37-71) years, underwent temporary, and subsequent permanent, stimulation. All had incontinence to solid or liquid stool; the aetiology was obstetric injury (seven patients), scleroderma (four), idiopathic (two), fistula surgery (one) and repaired rectal prolapse (one). Median duration of symptoms was 6 (range 2-15) years. Clinical evaluation, endoanal ultrasonography, bowel diary, quality of life questionnaire (Short Form (SF) 36) and anorectal physiological testing were performed before and after stimulation.

RESULTS

Continence had improved in all patients at median follow-up of 24 (range 3-60) months. Eleven patients were fully continent. Episodes of faecal incontinence decreased from median (range) 11 (2-30) per week before stimulation to 0 (0-4) per week after permanent stimulation (P < 0.001). Urgency improved in all patients (median (range) ability to defer less than 1 (0-1) versus 8 (1-15) min; P = 0.01). 'Social function' and 'role-physical' subscales of the SF36 improved significantly. Mean resting pressure (35 versus 49 cmH2O with temporary stimulation; P < 0.05) and squeeze pressure increment (43 versus 69 cmH2O with permanent stimulation; P < 0.01) increased. Rectal sensitivity to initial distension changed (mean 47 versus 34 ml air; P < 0.05). There were no major complications.

CONCLUSION

Sacral nerve stimulation is a safe and effective treatment for faecal incontinence when conventional treatment has failed. There is minimal morbidity. The benefit is maintained in the medium term.

Anorectal dysfunction in women with urinary incontinence or lower urinary tract symptoms

OBJECTIVES

(1) To evaluate the prevalence of anorectal dysfunction among women with urinary storage or voiding symptoms; and (2) to investigate the risk factors associated with anorectal symptoms.

METHODS

A sample of 320 women who attended the urogynecology outpatient clinic for urodynamic evaluation were requested to complete a structured questionnaire. The information collected included the medical, surgical, gynecological, and obstetric histories of the patients. Anal incontinence was defined as involuntary leakage of solid or liquid feces or gas. Constipation was defined as less than three bowel movements per week. Prevalence was estimated for anal incontinence and for constipation. A chi-square test was used to compare risk factors between women with and without anal incontinence or constipation. We used a multi-variable logistic regression analysis to estimate the association between other variables.

RESULT

Forty-nine (15.9%) women reported having anal incontinence according to the above definition. Of those 49 women, 11 (3.6%) experienced leakage of liquid and/or solid feces and 38 (12.3%) had flatus incontinence. Constipation was reported by 100 (31.5%) of the women. A multiple logistic regression analysis revealed that the main risk factor associated with anal incontinence and constipation was the presence of uterovaginal prolapse (odds ratio=5.02; 95% CI=2.19-11.5 for anal incontinence; odds ratio=1.78; 95% CI=1.03-3.09 for constipation).

CONCLUSION

Our results demonstrate a relatively high prevalence of anal incontinence or constipation among women suffering from urinary dysfunction. Uterovaginal prolapse is the main risk factor associated with anorectal dysfunction.

Physical therapies for prevention of urinary and faecal incontinence in adults

BACKGROUND

Physical therapies, particularly pelvic floor muscle training, have been recommended for prevention of incontinence associated with childbearing, and prostate surgery.

OBJECTIVES

To assess the effectiveness of physical therapies in preventing incontinence in adults.

SEARCH STRATEGY

The Cochrane Incontinence Group trials register was searched to September 2001. Trials were also sought from the Reference Lists of relevant articles and from experts in the field.

SELECTION CRITERIA

Randomised and quasi-randomised trials in adults without incontinence symptoms that compared a physical therapy with no treatment, or any other treatment to prevent incontinence.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed eligibility, trial quality and extracted data. Data were processed as described in the Cochrane Collaboration Handbook.

MAIN RESULTS

Two trials in men (155 men) and 13 trials in women (4661 women) were included. As most trials recruited regardless of continence status, and there was much heterogeneity, only a qualitative synthesis was undertaken. Three of seven trials in childbearing women reported less urinary incontinence after pelvic floor muscle training compared to control treatment three months postpartum. Two trials selected women at higher risk of postnatal incontinence. The third used an intensive training programme. Four trials did not find any difference between the groups at the primary endpoint. Two trials compared pre-prostate surgery pelvic floor muscle training with control treatment, and no difference in the occurrence of postoperative urinary incontinence was reported between the groups.

REVIEWER'S CONCLUSIONS

There is insufficient evidence to determine whether physical therapies can prevent incontinence in childbearing women, or men following prostate surgery. Further, better quality research is needed.

The prevalence and determinants of health care-seeking behavior for fecal incontinence in multiparous United Arab Emirates females

PURPOSE

This study was designed to determine the prevalence and sociodemographics of fecal incontinence in United Arab Emirates females.

METHODS

A representative sample of multiparous United Arab Emirates females aged 20 years or older (N = 450) were randomly selected from the community (n = 225) and health care centers (n = 225). Patients were interviewed about inappropriate stool loss in the past year using a structured and pretested questionnaire.

RESULTS

Fifty-one participants (11.3 percent) admitted fecal incontinence; 26 (5.8 percent) were incontinent to liquid stool and 25 (5.5 percent) to solid stool. Thirty-eight patients (8.4 percent) had double (urinary and fecal) incontinence. Sixty-five patients (14.4 percent) were incontinent to flatus only but not to stools. The association between having fecal incontinence and chronic constipation was significant (P < 0.0001), but there was no significant association with other known risk factors such as age, parity, and previous instrumental delivery, episiotomy, perineal tears, or anorectal operations. Only 21 incontinent patients (41 percent) had sought medical advice. Patients did not seek medical advice because they were embarrassed to consult their physician (64.7 percent), they preferred to discuss the difficulty with friends, assuming that fecal incontinence would resolve spontaneously (47.1 percent) or was normal (31.3 percent), and they chose self-treatment as a result of low expectations for medical care (23.5 percent). Sufferers were bothered by the inability to pray (92.2 percent) and to have sexual intercourse (43.1 percent). Perceived causes of fecal incontinence were paralysis (90.2 percent), old age (80.4 percent), childbirth (23.5 percent), or menopause (19.6 percent).

CONCLUSIONS

Fecal incontinence is common yet underreported by multiparous United Arab Emirates females because of cultural attitudes and inadequate public knowledge.

Advantages of a posterior fourchette incision in anal sphincter repair

PURPOSE

Delayed repair of obstetric-related anal sphincter injury remains problematic, and perineal wound breakdown is common. The aim of this study was to assess the outcome after overlap anal sphincter repair and to determine the advantages, if any, of a posterior fourchette incision (n = 18) compared with a conventional perineal incision (n = 32).

METHODS

Fifty females of mean parity 2.8 (standard deviation, 1.6) underwent repair in a five-year period. The mean follow-up was 23 months. Assessment was by anal vector manometry, endoanal ultrasound, and continence scoring.

RESULTS

Functional outcomes were similar in the two groups. Repair increased squeeze-pressure increment and improved continence scores in both groups. Postoperative wound complications were fewer when a posterior fourchette incision was used compared with a perineal incision (11 vs. 44 percent, respectively; P < 0.05).

CONCLUSIONS

Delayed anal sphincter repair improves continence. A posterior fourchette approach is associated with fewer postoperative wound complications without compromising the quality of repair and the functional outcome.

Association of non-urological diseases with lower urinary tract symptoms

OBJECTIVE

Clinical observations indicate that many non-urological diseases seem to be associated with lower urinary tract symptoms (LUTS). This has also been shown in studies usually concerning single diseases. This study investigated the impact of non-urological diseases on LUTS in the general population.

MATERIAL AND METHODS

A questionnaire on LUTS and medical history was mailed to all 50-, 60- and 70 year-old men in Tampere and in 11 municipalities in the same county, in total 3143 subjects. Day-time frequency, nocturia, urge, urge incontinence, hesitancy and incomplete emptying were used to form an index for LUTS. The men were asked to report any disease that they had. The number of the following diseases reported by the participants was large enough for statistical analysis: lower back pain, hypertension, arthritis, heart disease, pulmonary disease, diabetes, constipation. stroke, transient ischaemic attack, cancer (other than prostate or bladder), neurological disease, inguinal hernia, rheumatoid arthritis and faecal incontinence. The association between LUTS and non-urological diseases was estimated by logistic regression as a prevalence odds ratio (OR) with 95% confidence intervals (CI).

RESULTS

In the multivariate analysis a significant association was found between LUTS and the following diseases: faecal incontinence (OR 4.5, CI 2 .3-9.1), neurological disease (OR 2.4, CI 1.3-4.4), constipation (OR 2.3, CI 1.5-3.3) and arthritis (OR 1.5, CI 1.2-2.0).

CONCLUSIONS

According to this population-based study LUTS is an important part of the symptomatology of faecal incontinence, neurological disease, constipation and arthritis. Thus, the patients with these diseases and presenting with LUTS require careful investigation, at least in the cases in which the primary therapy of LUTS has failed.

The aetiology and epidemiology of faecal incontinence

Faecal incontinence is experienced by at least 2% of the population and 7% of those over 65 years of age. The true incidence is probably much higher because of the stigmata of the affliction leading to underreporting. The common causes of faecal incontinence are discussed.

Non-surgical management of faecal incontinence

Faecal incontinence is a common symptom causing reduction in quality of life and social isolation. Conservative treatments should be used as first and second lines of therapy and can also be of use as adjuncts to surgical treatment. This article reviews the current status of these modalities of treatment.

Clinical and economic evaluation of surgical treatments for faecal incontinence

BACKGROUND

Faecal incontinence affects 1-2 per cent of the adult population. While many patients can be managed successfully with conservative therapy, a small proportion require surgery. Improved imaging techniques and technological advances have led to the availability of a wide range of surgical treatments. Decision-makers increasingly require clinical and cost-effectiveness studies of surgical treatments for faecal incontinence. This review examines the practical aspects of undertaking such studies.

METHODS

The practical issues related to different aetiologies, different types of treatment, defining outcomes, the hidden costs of the condition and its treatment, the rapid changes in technology and issues of patient choice were all considered. A Medline search was undertaken to identify relevant publications, and the reference lists of identified papers were scanned manually.

RESULTS

There are few randomized controlled studies and those that have been performed have been limited in their scope. There has also been very limited health economic analysis undertaken. Strategies for conducting such studies, and the criteria they use, have been outlined.

CONCLUSION

Randomized trials have a limited role in this setting because of variations in aetiology, difficulty in standardizing procedures, continuing evolution of devices, small patient numbers, concerns for patient choice and the need for long-term follow-up. Issues to be addressed when evaluating interventions for faecal incontinence include choosing appropriate measures of surgical outcome, using new continence scoring systems and tools for quality-of-life assessment, and choosing appropriate cost perspectives and time horizons for economic evaluation.

Anal sphincter biofeedback and pelvic floor exercises for faecal incontinence in adults--a systematic review

BACKGROUND

Faecal incontinence is a common health care problem. Biofeedback is extensively used in clinical practice to treat faecal incontinence.

AIM

To systematically review and evaluate the evidence from clinical studies on the effectiveness of biofeedback as a treatment for faecal incontinence in adults.

METHODS

A systematic literature search was undertaken using electronic databases, with review of the retrieved references.

RESULTS

The search identified 46 studies published in English using biofeedback to treat adults complaining of faecal incontinence. Those studies included a total of 1364 patients. Of those studies with adequate data, 275 out of 566 patients (49%) were said to be cured of symptoms of faecal incontinence following biofeedback therapy and 617 out of 861 (72%) patients were reported to be cured or improved. Studies varied in the method of biofeedback used, criteria for success and the outcome measures used. Only eight of the 46 studies employed any form of control group.

CONCLUSIONS

The data suggest that biofeedback and exercises help a majority of patients with faecal incontinence. However, methodological variation, lack of controls and a lack of validated outcome measures are problems in evaluating these results.

Fecal Incontinence

Fecal incontinence is a socially devastating clinical condition. Initial symptomatic treatment includes exclusion of foods that precipitate the problem, increased use of fiber, and drug therapy with loperamide. Persistence of incontinence after these lifestyle modifications requires the physician to evaluate the internal and external anal sphincters. Anal endosonography and manometry provide an evaluation of sphincter structure and function. If an isolated muscle defect is seen, sphincteroplasty can be tried. If this surgical procedure is not indicated, biofeedback may be an option. Biofeedback should be considered for patients with neurogenic fecal incontinence, a weak but structurally intact external sphincter, or a decreased ability to perceive rectal distention. Muscle transposition to create a neosphincter should be offered only by surgeons with extensive experience performing this surgery. Because of the cosmetic sequela of colostomy, this surgery is often considered as a last-step procedure, despite being safe and effective.

Is there an association between fecal incontinence and lower urinary dysfunction?

BACKGROUND

Urinary and fecal incontinence in females are both common and distressing conditions. Because common pathophysiologic mechanisms have been described, an association between the two would be expected. The aim of this study was to determine whether patients with lower urinary tract dysfunction have concomitant fecal incontinence when compared with age and gender matched community controls and, second, to determine whether they have predisposing factors that have led to lower urinary tract symptoms and concomitant fecal incontinence.

METHODS

A case-control study was performed by means of detailed questionnaire and review of investigation results. One thousand consecutive females presenting for urodynamic investigation of lower urinary tract dysfunction, were compared with 148 age and gender matched community controls.

RESULTS

Frequent fecal incontinence was significantly more prevalent among all cases than among community controls (5 vs. 0.72 percent, P = 0.023). Occasional fecal incontinence was also more prevalent (24.6 vs. 8.4 percent, P < 0.001). Fecal incontinence was not significantly more prevalent among females with genuine stress incontinence (5.1 percent) when compared with females with detrusor instability (3.8 percent) or any other urodynamic diagnosis. Symptoms of fecal urgency and fecal urge incontinence were significantly more prevalent among those with a urodynamic diagnosis of detrusor instability or sensory urgency than among females with other urodynamic diagnoses or community controls. Multivariate analysis comparing cases with fecal incontinence with other cases and also with community controls did not indicate that individual obstetric factors contributed significantly to the occurrence of fecal incontinence in these patients.

CONCLUSIONS

There is an association between genuine stress incontinence, lower urinary tract dysfunction, and symptoms of fecal incontinence, but the exact mechanism of injury related to childbirth trauma is questioned.

Pathophysiology and management of bowel dysfunction in multiple sclerosis

The prevalence of bowel dysfunction in multiple sclerosis (MS) patients is higher than in the general population. Up to 70% of patients complain of constipation or faecal incontinence, which may also coexist. This overlap can relate to neurological disease affecting both the bowel and the pelvic floor muscles, or to treatments given. Bowel dysfunction is a source of considerable ongoing psychosocial disability in many patients with MS. Symptoms related to the bladder and the bowel are rated by patients as the third most important, limiting their ability to work, after spasticity and incoordination. Bowel management in patients with MS is currently empirical. Although general recommendations include maintaining a high fibre diet, high fluid intake, regular bowel routine, and the use of enemas or laxatives, the evidence to support the efficacy of these recommendations is scant. This review will examine the current state of knowledge regarding the pathophysiological mechanisms underlying bowel dysfunction in MS, outline the importance of proper clinical assessment of constipation and faecal incontinence during the diagnostic work-up, and propose various management possibilities. In the absence of clinical trial data on bowel management in MS, these should be considered as a consensus on clinical practice from a team specialized in bowel dysfunction.

Treatment options for fecal incontinence

PURPOSE

Fecal incontinence is a socially devastating disorder which affects at least 2.2 percent of community dwelling adults and 45 percent of nursing home residents. Most incontinent patients can be helped, but physicians are poorly informed about treatment options. The aim of this study was to develop a consensus on treatment options by convening a conference of surgeons, gastroenterologists, nurses, psychologists, and patient advocates.

METHOD

A 1-1/2 day conference was held in April, 1999. Experts from different disciplines gave overviews, followed by extended discussions. Consensus statements were developed at the end of the conference. This summary statement was drafted, circulated to all participants, and revised based on their input.

CONCLUSIONS

1) Diarrhea is the most common aggravating factor for fecal incontinence, and antidiarrheal medications such as loperamide and diphenoxylate or bile acid binders may help. Fecal impaction, a common cause of fecal incontinence in children and elderly patients, responds to combinations of laxatives, education, and habit training in approximately 60 percent. These causes of fecal incontinence can usually be identified by history and physical examination alone. 2) In patients who fail medical management or have evidence of sphincter weakness, anorectal manometry and endoanal ultrasound are recommended as helpful in differentiating simple morphologic defects from afferent and efferent nerve injuries and from combined structural and neurologic injuries. 3) Biofeedback is a harmless and inexpensive treatment which benefits approximately 75 percent of patients but cures only about 50 percent. It may be most appropriate when there is neurologic injury (i.e., partial denervation), but it has been reported to also benefit incontinent patients with minor structural defects. 4) External anal sphincter plication with or without pelvic floor repair is indicated when there is a known, repairable structural defect without significant neurologic injury. It is effective in approximately 68 percent. 5) Salvage operations are reserved for patients who can not benefit from biofeedback or levator-sphincteroplasty. These include electrically stimulated gracilis muscle transpositions and colostomy. 6) Antegrade enemas delivered through stomas in the cecum or descending colon reduce or eliminate soiling in approximately 78 percent of children with myelomeningocele; this operation may come to be more widely applied. 7) Investigational treatments include implanted nerve stimulators, artificial sphincters, and anal plugs. 8) Patient characteristics which influence choice of treatment include mental status, mobility impairment, and typical bowel habits. 9) Additional research is needed to better define the mechanisms responsible for fecal incontinence, to assess the efficacy of these treatments, to develop better treatments for nursing home residents, and to identify predictors of outcome.

Neosphincters in the management of faecal incontinence

BACKGROUND

Surgical treatment of end-stage faecal incontinence has its origin in the early 1950s. Interest has been revived as a result of technical advances achieved in the recent past. The purpose of this article is to review the principles that underlie the use of skeletal muscle transposition around the anal canal and of electrical stimulation in the treatment of incontinence, and to explore new methods of treatment of this condition.

METHODS

A literature search was performed using Pubmed and Medline, employing keywords related to treatment of faecal incontinence by neosphincter reconstruction. Basic science and clinical aspects of neosphincter reconstruction were gathered from relevant texts, original articles and recently published abstracts.

RESULTS

The electrically stimulated gracilis neoanal sphincter seems to be the popular choice of biological neosphincter. It is more likely to produce higher resting anal canal pressures than the unstimulated neosphincter, and hence improved continence. However, electrostimulator failure may result in explantation in a proportion of patients. Impairment of evacuation is a functional setback in approximately one-third of patients with the gracilis neosphincter. Overall, improvement of continence may be expected in up to 90 per cent of patients according to some reports. By contrast, experience with the artificial neosphincter, which is less expensive, has been limited to a few tertiary centres across the world. Reported continence of stool is 100 per cent, and that of gas and stool 50 per cent, following implantation of the artificial sphincter. Both of the above operations have been associated with implant-related infection and impaired evacuation.

CONCLUSION

Neoanal sphincter operations are technically demanding, require a considerable learning experience and should be confined to specialist colorectal centres. Patients are likely to benefit from a plan that incorporates preoperative counselling and a selective approach.

Postanal repair for fecal incontinence--is it worthwhile?

PURPOSE

Patients with idiopathic or neurogenic incontinence without an isolated sphincter defect may be suitable candidates for a postanal repair. The aim of this study was to assess the results of postanal repair in patients with idiopathic or neurogenic fecal incontinence and to evaluate the role of various parameters, including preoperative physiologic testing on outcome.

METHODS

Postanal repair was offered by a single surgeon to patients meeting the following criteria: incontinence score of at least 12 of 20, absence of an isolated anterior external anal sphincter defect, and failed conservative, medical, and biofeedback management. Physiologic investigation and clinical findings of female patients who had postanal repair for fecal incontinence between 1992 and 1998 were reviewed. Physiologic investigation included anorectal manometry, pudendal nerve terminal motor latency, concentric needle electromyography, and endoanal ultrasonography. Follow-up was obtained by telephone questionnaire; moreover, patients were asked to grade the outcome of their surgery as excellent or good (success) or as fair or poor (failure).

RESULTS

Twenty-one patients of median age 68 (range, 40-80) years had a mean duration of fecal incontinence before postanal repair of 6.8 (range, 0.5-22) years. Twenty patients (95 percent) were available for at least one year of follow-up. Seventeen patients (80.9 percent) had at least one prior vaginal delivery, and prior sphincteroplasty had been performed in 10 patients (47.6 percent). The morbidity and mortality rates were 5 and 0 percent, respectively. After a mean follow-up period of three (range, 1-7.5) years, seven patients (35 percent) considered surgery to be successful and had a statistically significant decrease in their incontinence score. Neither prolongation of pudendal nerve terminal motor latency nor external sphincter damage as noted on electromyography or any of the preoperative manometric parameters correlated with outcome. Furthermore, patients' ages at surgery did not correlate with the degree of postoperative improvement in continence scores nor did the duration of the patients' symptoms, number of vaginal deliveries, or a history of previous surgery for fecal incontinence.

CONCLUSION

None of the factors assessed was demonstrated to be predictive of outcome after postanal repair; moreover, the currently available preoperative testing has not altered the success rate, which remains low (35 percent). Despite the low success rate, the absence of any mortality and the low morbidity suggest that postanal repair may be a valid therapeutic approach. However, it should be offered only to selected patients with persistent, severe fecal incontinence despite an anatomically intact external anal sphincter who are not candidates for or refuse all other operative modalities.

Factors predictive of outcome after surgery for faecal incontinence

BACKGROUND

Surgical treatment of faecal incontinence may be categorized into procedures that either repair or augment the native sphincter mechanism or, alternatively, require construction of a neosphincter using either autologous tissue or an artificial device.

METHODS

This article reviews the currently available surgical options for the treatment of faecal incontinence, discusses factors predictive of outcome, and includes an algorithm for treatment.

RESULTS AND CONCLUSION

Procedures such as postanal repair, direct sphincter repair and reefing are seldom used. Overlapping repair has become the operation of choice in incontinent patients with isolated anterior defects in the external anal sphincter muscle, particularly in postobstetric trauma. Pudendal neuropathy seems to be a predictive factor of success, although this is not universally accepted. Total pelvic floor repair has been offered as a recent alternative. Neosphincter procedures include a gluteoplasty, non-stimulated and stimulated unilateral or bilateral graciloplasty and artificial bowel sphincter. The success and morbidity rates with the stimulated graciloplasty and artificial bowel sphincter appear similar. The newest alternative, sacral nerve stimulation, seems promising. In the final analysis, case selection and surgical judgement are probably the most important factors influencing the success of surgery for faecal incontinence. Presented as the Edinburgh Royal College of Surgeons invited lecture to the Association of Coloproctology of Great Britain and Ireland, Southport, UK, June 1999

Restoring control: the Acticon Neosphincter artificial bowel sphincter in the treatment of anal incontinence

PURPOSE

Anal incontinence is a socially disabling problem affecting 1 to 2 percent of the population. Anal sphincter replacement is a treatment option if the problem is severe and not amenable to direct repair. The artificial bowel sphincter is an innovative approach. We report the technique for placement and the outcomes which have occurred in an initial series of 13 patients.

METHODS

The Acticon Neosphincter artificial bowel sphincter consists of an inflatable cuff of silicone elastomer placed around the anal canal and connected to a pressure-regulating balloon in the iliac fossa via a control pump placed in the labium or scrotum. Thirteen patients with severe anal incontinence not amenable to other methods were treated. Causes of incontinence included obstetric damage in eight patients, surgical damage in two patients, imperforate anus in two patients, and spina bifida in one patient.

RESULTS

Surgical placement of the device was straightforward, mean operating time was 65 minutes, and median length of stay was 3.6 days. One infection of the perineal wound occurred in the early postoperative period necessitating removal of the device. In two further patients the artificial bowel sphincter was removed because of late infection in one at seven months and because of erosion through the skin in another at three months. The artificial bowel sphincter has been activated in ten patients resulting in full continence to solids and liquids except in one patient with postvagotomy diarrhea who had some leakage of liquids during episodes of diarrhea. The mean (+/- standard deviation) continence score (Cleveland Clinic system; maximal incontinence = 20) changed from 18.7 +/- 1.6 preoperatively to 2.1 +/- 2.6 after activation (P < 0.0001). Quality of life measured using a continence-specific series of up to 39 questions changed from 77 +/- 16 percent of maximal reduction of quality preoperatively to 12 +/- 19 percent postoperatively (P < 0.001).

CONCLUSIONS

The artificial bowel sphincter can be placed without technical difficulty and with low morbidity. Preliminary experience shows full restoration of continence in most patients and ease of use. Longer follow-up is needed to determine the extent of problems with infection, erosion, and mechanical failure.

Anal incontinence: prevalence among female patients attending a urogynecologic clinic

The present study prospectively surveyed the prevalence of anal incontinence among 283 consecutive female patients attending a urogynecologic outpatient clinic in a maternity hospital. Data concerning bowel habits, laxative use, previous anorectal surgery, and the presence, severity, and frequency of anal incontinence were collected by interviewing the patients. Anal incontinence was reported by 83 women, representing 29% of the study population. Of those reporting anal incontinence, 30% (9% of the study population) were incontinent to solid feces, 22% (6%) to liquid feces, and 48% (14%) to gas. Age distribution demonstrates progressive rise and a high prevalence of anal incontinence in patients older than 60 years. A significant higher rate of vacuum deliveries was found among patients with anal incontinence, compared with continent patients (9.6% vs. 2.5%; P = 0.01). Increased prevalence of anal incontinence was also found among patients with past history of hemorrhoidectomy and those with urodynamic diagnosis of combined genuine stress incontinence and detrusor instability/sensory urgency. In conclusion, in patients attending a urogynecologic clinic, anal incontinence is a frequent, although rarely volunteered, symptom.

Fecal incontinence in hospitalized patients who are acutely ill

BACKGROUND

Information about fecal incontinence experienced by patients in acute-care settings is lacking. The relationship of fecal incontinence to several well-known nosocomial or iatrogenic causes of diarrhea has not been determined.

OBJECTIVES

To determine the cumulative incidence of fecal incontinence in hospitalized patients who are acutely ill, and to ascertain the relationship between fecal incontinence and stool consistency, and between diarrhea and two well-known nosocomial or iatrogenic etiologies of diarrhea: Clostridium difficile and tube feeding. The relationship of fecal incontinence and risk factors for diarrhea associated with C. difficile and tube feeding in hospitalized patients was examined.

METHODS

Fecal incontinence, stool frequency and consistency, administration of tube feeding and medications, severity of illness, and nutritional data were prospectively recorded in 152 patients on acute or critical care units of a university-affiliated Veterans' Affairs Medical Center. Rectal swabs and stool specimens from patients were obtained weekly for C. difficile culture. C. difficile culture and cytotoxin assay were performed on diarrheal stools. HindIII restriction endonuclease analysis (REA) was used for typing of C. difficile isolates.

RESULTS

In this study, 33% (50/152) of the patients had fecal incontinence. The proportion of total surveillance days with fecal incontinence in these patients was 0.50 +/- 0.06. A greater percentage of patients with diarrhea had fecal incontinence than patients without diarrhea (23/53 [43%] vs. 27/99 [27%]; p = 0.04). Incontinence was more frequent in patients with loose/liquid stool consistency than in patients with hard/soft stool consistency (48/50 [96%] vs. 71/100 [71%]; p < 0.001). The proportion of surveillance days with fecal incontinence was related to the proportion of surveillance days with diarrhea (r = 0.69; p < 0.001) and the proportion of surveillance days with loose/liquid stools (r = 0.64; p < 0.001). Multivariate risk factors for fecal incontinence were unformed/loose or liquid consistency of stool (RR = 11.1; 95% confidence interval [CI] = 2.2, 56.7), severity of illness (RR = 5.7; CI = 2.6, 12.3), and age (RR = 1.1; CI = 1, 1.1).

CONCLUSIONS

Fecal incontinence is common in hospitalized patients who are acutely ill, but the condition was not associated with any specific cause of diarrhea. Because loose or liquid stool consistency is a risk factor for fecal incontinence, use of treatments that result in a more formed stool may be beneficial in managing fecal incontinence. However, treatments that slow intestinal transit should be avoided in patients with C. difficile-associated diarrhea.

Validation of a questionnaire to assess fecal incontinence and associated risk factors: Fecal Incontinence Questionnaire

PURPOSE

Although fecal incontinence is a topic of considerable importance, there are no validated self-report measures of fecal incontinence available. The aim of this study was to develop a questionnaire to measure fecal incontinence and its risk factors in the community.

METHOD

The reliability and concurrent validity of the fecal incontinence questionnaire were measured by test-retest procedures in a population of clinic patients. The questionnaire was created for a sixth-grade reading level, with large print. Ninety-four adult patients were surveyed. Thirty-four patients repeated the questionnaire through the mail. Forty-one patients were independently retested over the telephone by a physician to assess concurrent validity. Nine patients refused retest, and ten patients did not respond to a second contact.

RESULTS

The fecal incontinence questionnaire was well understood and well accepted. Reliability (overall median kappa, 0.68; interquartile range, 0.03-1) and validity (overall median kappa, 0.59; interquartile range, 0.27-1) were acceptable for the mailed retest and the telephone retest, respectively. The presence of fecal incontinence as measured by questionnaire was greatly increased when compared with physician history in clinical records; only 3 percent of patients reported no fecal incontinence on the questionnaire when the clinic chart had documented this problem.

CONCLUSION

Our initial results indicated that this new self-report questionnaire is a useful tool for assessing the presence of fecal incontinence in the population and has greater sensitivity compared with a standard physician interview. Specific attention should be given to identifying fecal incontinence and associated symptoms during history taking.

Biofeedback and/or sphincter exercises for the treatment of faecal incontinence in adults

BACKGROUND

Faecal incontinence is a particularly embarrassing and distressing condition with significant medical, social and economic implications. Sphincter exercises and biofeedback therapy have been used to treat the symptoms of people with faecal incontinence. However, standards of treatment are still lacking and the magnitude of alleged benefits has yet to be established.

OBJECTIVES

To determine the effects of biofeedback and/or anal sphincter exercises/pelvic floor muscle training for the treatment of faecal incontinence in adults.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group trials register, the Cochrane Controlled Trials Register, Medline, Embase and all reference lists of relevant articles up to November 1999. Date of the most recent searches: November 1999.

SELECTION CRITERIA

All randomised or quasi-randomised trials evaluating biofeedback and/or anal sphincter exercises in adults with faecal incontinence.

DATA COLLECTION AND ANALYSIS

Three reviewers assessed the methodological quality of eligible trials and two reviewers independently extracted data from included trials. A wide range of outcome measures were considered.

MAIN RESULTS

Only five eligible studies were identified with a total of 109 participants. In the majority of trials methodological quality was poor or uncertain. All trials were small and employed a limited range of outcome measures. Follow-up information was not consistently reported amongst trials. Only two trials provided data in a form suitable for statistical analyses. There are suggestions that rectal volume discrimination training improves continence more than sham training and that anal biofeedback combined with exercises and electrical stimulation provides more short-term benefits than vaginal biofeedback and exercises for women with obstetric-related faecal incontinence. Further conclusions are not warranted from the available data.

REVIEWER'S CONCLUSIONS

The limited number of identified trials together with their methodological weaknesses do not allow a reliable assessment of the possible role of sphincter exercises and biofeedback therapy in the management of people with faecal incontinence. There is a suggestions that some elements of biofeedback therapy and sphincter exercises may have a therapeutic effect, but this is not certain. Larger well-designed trials are needed to enable safe conclusions.

Electrical stimulation for faecal incontinence in adults

BACKGROUND

Faecal incontinence is a particularly embarrassing and distressing condition with significant medical, social and economic implications. Electrical stimulation has been used with apparent success in the treatment of faecal incontinence. However, standards of treatment are still lacking and the magnitude of alleged benefits has yet to be established.

OBJECTIVES

To determine the effects of electrical stimulation for the treatment of faecal incontinence in adults.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group trials register, the Cochrane Controlled Trials Register, Medline, Embase and reference lists of potentially eligible articles up to November 1999. Date of the most recent searches: November 1999.

SELECTION CRITERIA

All randomised or quasi-randomised trials evaluating electrical stimulation in adults with faecal incontinence.

DATA COLLECTION AND ANALYSIS

Three reviewers assessed the methodological quality of potentially eligible trials and two reviewers independently extracted data from the included trial. A wide range of outcome measures were considered.

MAIN RESULTS

Only one eligible trial with 40 participants was identified. It was a randomised trial, but it suffered from methodological drawbacks and did not follow up patients beyond the end of the trial period. Findings from this trial suggest that electrical stimulation with anal biofeedback and exercises provides more short-term benefits than vaginal biofeedback and exercises for women with obstetric-related faecal incontinence. No further conclusions could be drawn from the data available.

REVIEWER'S CONCLUSIONS

At present, there are insufficient data to allow reliable conclusions to be drawn on the effects of electrical stimulation in the management of faecal incontinence. There is a suggestion that electrical stimulation may have a therapeutic effect, but this is not certain. Larger, more generalisable trials are needed.

Randomized controlled trial of topical phenylephrine in the treatment of faecal incontinence

BACKGROUND

Anal incontinence due to internal sphincter dysfunction is not amenable to simple surgical repair. The alpha-adrenergic agonist phenylephrine produces contraction of the internal sphincter and raises resting pressure when applied topically in healthy volunteers. The effect of topical phenylephrine in the treatment of faecal incontinence due to internal sphincter dysfunction was investigated.

METHODS

Thirty-six patients (22 women) aged 28-81 (mean 58) years with faecal incontinence and ultrasonographically structurally normal anal sphincter muscles were treated with topical 10 per cent phenylephrine and placebo gels, allocated in random order in a double-blind crossover study. Maximum resting anal sphincter pressure and anodermal blood flow were measured. A symptom questionnaire was completed and incontinence score determined using a validated scale.

RESULTS

There were no significant differences in incontinence score, resting anal pressure and anodermal blood flow between the active and placebo treatments. Six patients on active treatment and two on placebo experienced more than 75 per cent subjective improvement. Three patients developed allergic dermatitis to phenylephrine.

CONCLUSION

This is the first study of the use of a topical pharmacological agent to treat faecal incontinence. This concentration of topical phenylephrine did not produce a significant improvement in symptoms or function. A subgroup of patients may respond. Further studies are required with increased concentrations.

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 (e.g. pelvic floor muscle training, biofeedback, drugs) and surgical procedures. Surgery is used in selected groupsof people when the structural and functional defects in the pelvic floor muscles or the anal sphincter complex can be corrected mechanically.

OBJECTIVES

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

SEARCH STRATEGY

We searched the Cochrane Incontinence Group trials register, the Cochrane Colorectal Cancer Group trials register, the Cochrane Controlled Trials Register (Issue 2, 1999), Medline (up to March 1999), Embase (1998 up to January 1999), Sigle (1980 up to December 1996), Biosis (1998 up to March 1999), SCI (1998 up to March 1999), ISTP (1982 up to March 1999) and the reference lists of relevant articles. We specifically hand searched the British Journal of Surgery from 1995 to 1998 and the Diseases of the Colon and Rectum from 1995 to 1998. We also perused the proceedings of the Association of Coloproctology, meeting 1999. Date of the most recent literature searches: March 1999.

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

Four trials were included with a total sample size of 110 participants. All trials excluded women with anal sphincter defects detected by endoanal ultrasound examination. No trial included a group managed non-surgically. Two trials (56 participants) compared three approaches to pelvic floor repair (anterior levatorplasty, postanal repair and their combination total pelvic floor repair). One trial (30 participants) evaluated adding plication of the anal sphincter to total pelvic floor repair. The fourth trial (24 participants) compared a neosphincter procedure with total pelvic floor repair. No differences in the primary outcomes were detected, but data were few and inconsistently reported.

REVIEWER'S CONCLUSIONS

The small number of relevant trials identified together with their small sample sizes and other methodological weaknesses severely 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 needed.

Stimulated graciloplasty for treatment of intractable fecal incontinence: critical influence of the method of stimulation

INTRODUCTION

Patients with end-stage fecal incontinence, in whom all standard medical and surgical treatment has failed or is not expected to be effective, can be treated by stimulated graciloplasty. The aim of the present study was to assess the efficacy of stimulated graciloplasty by both direct nerve and intramuscular perineural stimulation techniques and to evaluate various parameters relative to outcome.

METHODS

A prospective analysis of all patients who underwent this procedure was undertaken. All patients were preoperatively investigated by anal manometry, electromyography, pudendal nerve terminal motor latency assessment, endoanal ultrasound, and an enema retention test. They were further assessed with an incontinence scoring system and a Quality of Life Questionnaire. Postoperative evaluation included anorectal manometry, incontinence score registry, and a Quality of Life Questionnaire. In our initial experience the stimulation system electrodes were fixed directly to the nerve (direct nerve stimulation graciloplasty); later in the study the stimulation system electrodes were fixed intramuscularly close to the nerve branches (intramuscular perineural stimulation graciloplasty).

RESULTS

From May 1993 to February 1998, 27 patients underwent 33 gracilis transpositions for fecal incontinence, 30 of which were stimulated. Six of the patients with direct nerve stimulation graciloplasty eventually had the direct nerve stimulator removed and replaced with an intramuscular electrode stimulator. After an mean follow-up (until the time of exit from study) of 12.5 (range, 1-23) months for direct nerve stimulation graciloplasty and 21 (range, 8-27) months for intramuscular perineural stimulation graciloplasty, 13 graciloplasties (43 percent) were successful. There was no correlation between outcome of surgery and age, duration or cause of symptoms, body habitus, manometric or electromyographic parameters, prior sphincter repair, the presence of a pre-existing stoma, or any immediate postoperative complications. However, the number of patients with intramuscular perineural stimulation graciloplasty who had a successful outcome (continent, 69 percent; improved but not fully continent, 23 percent; incontinent, 8 percent) was significantly higher than patients with direct nerve stimulation graciloplasty (improved but not fully continent, 10 percent; incontinent, 90 percent).

CONCLUSION

The success of stimulated graciloplasty is dependent on the method of nerve stimulation, whereas surprisingly, none of the many other factors assessed influenced outcome.

Safety and efficacy of dynamic muscle plasty for anal incontinence: lessons from a prospective, multicenter trial

BACKGROUND & AIMS

Dynamic muscle plasty has been advocated as therapy for refractory fecal incontinence and for anorectal reconstruction to avoid colostomy after abdominoperineal resection. This study evaluates the results of a multicenter experience with dynamic muscle plasty in the treatment of fecal incontinence and total anal reconstruction.

METHODS

One hundred thirty-nine patients were enrolled at 12 centers between June 1992 and November 1994 and followed up through June 1996. Intramuscular leads and neurostimulators were implanted to stimulate transposed gracilis or gluteus muscle. Success was defined as 70% reduction in solid stool incontinence for patients with baseline incontinence and zero incontinence to solid stool for patients with baseline stomas and for patients undergoing total anal reconstruction.

RESULTS

Overall, 85 of 128 graciloplasty patients (66%) achieved and maintained a successful outcome over the follow-up period. By etiology, these proportions were 71%, 50%, and 66% for patients with acquired fecal incontinence, congenital incontinence, and total anal reconstruction, respectively. One third of graciloplasty patients experienced a major wound complication, with therapy failing in 41%. Experienced centers had better outcomes and lower complication rates than inexperienced centers. Of the 11 gluteoplasty patients, 5 (45%) achieved and maintained a successful outcome.

CONCLUSIONS

Dynamic graciloplasty may be an effective procedure for patients with refractory, end-stage fecal incontinence as well as for patients who require anorectal excision for low-lying malignancy. However, the procedure has significant morbidity that can lead to functional failure. Outcome after dynamic graciloplasty appears to correlate with surgical experience. In contrast to graciloplasty, the use of dynamic gluteoplasty should be limited to investigational purposes.

Rectal prolapse and fecal incontinence

Rectal prolapse and fecal incontinence are problems with enormous social, functional, and economic significance to hundreds of thousands of people every year. Through a knowledgeable approach and careful diagnostic studies, many people can be cured or helped.

Incidence and obstetric risk factors of postpartum anal incontinence

BACKGROUND

Anal incontinence in young women may be the result of injury to the pelvic floor during vaginal delivery. This study was conducted to evaluate the relationship between obstetric risk factors and the prevalence of anal incontinence 3 months and 1 year after delivery.

METHODS

Three hundred consecutive women who delivered in the obstetric ward of the Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, were prospectively interviewed 3 months postpartum with regard to the symptom of anal incontinence. Patients with anal incontinence that started after delivery were questioned about the type, frequency, and severity of the problem, concomitant stress urinary incontinence (SUI), previous colorectal assessment, and wish for further evaluation and treatment. Obstetric data were collected from the women's medical charts. Symptomatic patients were followed-up 1 year postpartum.

RESULTS

Anal incontinence was reported by 21 patients: 19 were incontinent to gas, whereas only 2 patients were incontinent to solid feces (6.3% and 0.7% of the study population, respectively). Five patients (24% of the anal-incontinent patients) also had concomitant SUI. The length of the first and second stages of labor, operative vaginal delivery, and episiotomy were found to be associated (P < 0.05) with the development of anal incontinence at 3 months postpartum. At I year postpartum all patients with combined anal incontinence and SUI had persistent symptoms.

CONCLUSION

The major obstetric risk factors for postpartum anal incontinence are prolonged first and second stages of labor, operative vaginal delivery, and the use of episiotomy.

Topical phenylephrine increases anal sphincter resting pressure

BACKGROUND

Phenylephrine is an alpha1-adrenergic agonist which causes contraction of human internal anal sphincter muscle in vitro. Its intra-arterial administration in animals has been shown to increase resting sphincter pressure in vivo. In this study the effect of topical application of phenylephrine on resting anal pressure in healthy human volunteers was investigated.

METHODS

Twelve healthy volunteers had measurements of maximum resting sphincter pressure (MRP) and anodermal blood flow taken before and after topical application of increasing concentrations of phenylephrine gel to the anus. To determine the duration of effect of the agent, readings were taken throughout the day after a single application.

RESULTS

There was a dose-dependent rise in the resting anal sphincter pressure, with a small 8 per cent rise after 5 per cent phenylephrine (P = 0.012) and a larger 33 per cent rise with 10 per cent phenylephrine (mean(s.d.) MRP 85(12) cmH2O before versus 127(12) cmH2O after treatment, P < 0.0001). Thereafter no additional response was noted with higher concentrations of phenylephrine. The median duration of action of a single application of 10 per cent phenylephrine was 7 (range from 6 to more than 8) h.

CONCLUSION

Topical application of 10 per cent phenylephrine gel to the anus produces a significant rise in the resting anal sphincter pressure in healthy human volunteers. This represents a potential novel therapeutic approach to the treatment of passive faecal incontinence associated with a low resting anal sphincter pressure.

Epidemiology and natural history of pelvic floor dysfunction

Pelvic floor dysfunction, including urinary incontinence, anal incontinence, and pelvic organ prolapse, is extremely common, affecting at least one-third of adult women. A minority of patients sustaining these conditions volunteer their symptoms. Risk factor identification and the development of tactics for prevention are significant priorities for future research. Understanding both the specific predisposing factors that place an individual woman at risk and the precise events of the labor and delivery process that initiate injury and dysfunction is important for primary prevention. Defining the relative importance of various promoting and decompensating factors is essential for secondary prevention.

Third-degree obstetric perineal tear: long-term clinical and functional results after primary repair

BACKGROUND

This study was designed to investigate the long-term clinical and anorectal functional results after primary repair of a third-degree obstetrical perineal rupture.

METHODS

One hundred and fifty-six consecutive women who had a primary repair of a third-degree perineal rupture were sent a questionnaire and asked to undergo anorectal function testing (anal manometry, anorectal sensitivity, anal endosonography and pudendal nerve terminal motor latency (PNTML)) RESULTS: Some 117 women (75 per cent) responded. Anal incontinence was present in 47 women (40 per cent); however, in most cases only mild symptoms were present. In 40 women additional anorectal function tests were performed and compared with findings in normal controls. Mean(s.d.) maximum squeeze pressure (31(15) versus 63(17) mmHg, P< 0.001) was decreased and first sensation to filling of the rectum (88(47) versus 66(33) ml, P=0.03) and anal mucosal electrosensitivity (4.7(1.7) versus 2.5(0.8) mA, P=0.003) were increased compared with values in normal controls. In 35 women (88 per cent) a sphincter defect was found with anal endosonography. Factors related to anal incontinence were the presence of a combined anal sphincter defect (relative risk (RR) 1.7 (95 per cent confidence interval (c.i.) 1.1-2.8)) or subsequent vaginal delivery (RR 1.6 (95 per cent c.i. 1.1-2.5)).

CONCLUSION

Anal incontinence prevails in 40 per cent of women 5 years after primary repair of a third-degree perineal rupture. The presence of a combined sphincter defect or subsequent vaginal delivery increase the risk of anal incontinence.

Fecal incontinence in Wisconsin nursing homes: prevalence and associations

INTRODUCTION

This report determines the characteristics and health histories that are associated with fecal incontinence in a nursing home population.

METHODS

A cross-sectional survey is reported comprised of data from the Health Care Finance Administration's Minimum Data Set submitted by Wisconsin skilled nursing facilities to the Wisconsin Center for Health Statistics' Annual Nursing Home Survey in 1992 and 1993. Demographic characteristics, functional status, and disease history were correlated with the dependent variable, fecal incontinence.

RESULTS

In both 1992 and 1993, significant positive associations with fecal incontinence included the following, in order of adjusted odds ratios: urinary incontinence, tube feeding, any loss of activities of daily living, diarrhea, truncal restraints, pressure ulcers, dementia, impaired vision, fecal impaction, constipation, male gender, age, and increasing body mass index. Significant inverse associations were noted for heart disease and depression in one of the years and arthritis in both years. In both years, diabetes was not associated with fecal incontinence.

CONCLUSION

Urinary incontinence frequently coexists with fecal incontinence. The treatment of fecal incontinence may depend more on awareness of these significant associations, such as tube feeding, impaction, diarrhea, and loss of activities of daily living, which might exacerbate fecal incontinence, than on the condition of the anal sphincter.

A prospective study of anal sphincter injury due to childbirth

BACKGROUND

Faecal incontinence commonly affects women, principally because of childbirth. Our aims were to determine the functional effect of childbirth on the pressures generated by the anal sphincter and to determine the patterns of injury to the sphincter.

METHODS

Anal manometry was performed in 53 primiparous women prenatally, in 50 women at a median of 5 weeks postnatally, and repeated in 26 women at a median of 6 months postnatally. In addition, anal ultrasound was performed postnatally. Pelvic floor symptoms were assessed. The mode of delivery was examined to determine what variables affected anal function.

RESULTS

Squeeze pressure was significantly reduced (P < 0.001) 6 weeks postnatally (mean, 170.4 cm H2O; standard deviation (s), 56) compared with the prenatal value (mean, 225.6 cm H2O; s, 58). This occurred in symptomatic and asymptomatic women and in women with a normal anal ultrasound. Resting pressure was significantly reduced at 6 weeks (P < 0.001; prenatal mean, 91.6 cm H2O; s, 25; postnatal mean, 80.Ocm H2O; s, 21). Delivery method (vaginal or caesarean) was the only factor significant for the reduced squeeze pressure (r=53.377; standard error, 13.973; P < 0.001). Sphincter defects (41%) were common but did not influence anal sphincter function.

CONCLUSION

Anal function was significantly affected by vaginal delivery with short-duration follow-up. This occurred with and without evidence of an anal sphincter injury. The importance of a sphincter injury is questioned.

Stroke and incontinence

BACKGROUND

Urinary incontinence in the acute stage of stroke is seen as a predictor of death, severe disability, and an important factor on hospital discharge destination. Therefore, it is an important measure of stroke severity that not only affects the lives of stroke survivors but also those of caregivers.

SUMMARY OF REVIEW

A number of studies have linked the presence of bladder dysfunction in stroke survivors to various neurological lesions in areas thought to be primarily involved in micturition. However, neurological deficits may affect management of bladder control secondarily by apraxia or aphasia, for example, and a significant number of strokes occur in individuals already experiencing incontinence.

CONCLUSIONS

Despite incontinence being such an important prognostic feature, there are many gaps in our knowledge of the relationship of stroke and incontinence, particularly fecal incontinence. There are almost no studies on the influence of achieving continence on outcome or how this might be brought about. This article reviews the literature on this important topic and highlights deficiencies in our knowledge and areas of future research.