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Luo C, Wei D, Pang K, Mei L, Chen Y, Niu X. Is percutaneous tibial nerve stimulation (PTNS) effective for fecal incontinence (FI) in adults compared with sham electrical stimulation? A meta-analysis. Tech Coloproctol 2024; 28:37. [PMID: 38401006 DOI: 10.1007/s10151-024-02910-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 01/27/2024] [Indexed: 02/26/2024]
Abstract
BACKGROUND Sacral nerve neuromodulation (SNM) has been considered the optimal second-line treatment for fecal incontinence (FI). However, SNM involves high cost and requires highly skilled operators. Percutaneous tibial nerve stimulation (PTNS) has emerged as an alternative treatment modality for FI, yielding varying clinical outcomes. We conducted this meta-analysis to evaluate the effectiveness and safety of PTNS compared to sham electrical stimulation for FI. METHODS PubMed, Embase, Web of Science, and the Cochrane Library were searched for studies from May 12, 2012 to May 12, 2022. RESULTS Four randomized controlled studies were included in this review, involving a total of 439 adult patients with FI (300 in the PTNS group and 194 in the sham electrical stimulation group). Our meta-analysis revealed that PTNS demonstrated superior efficacy in reducing weekly episodes of FI compared to the control groups (MD - 1.6, 95% CI - 2.94 to - 0.26, p = 0.02, I2 = 30%). Furthermore, a greater proportion of patients in the PTNS group reported more than a 50% reduction in FI episodes per week (RR 0.73, 95% CI 0.57-0.94, p = 0.02, I2 = 6%). However, no significant differences were observed in any domains of the FI Quality of Life (QoL) and St Mark's incontinence scores (MD - 2.41, 95% CI - 5.1 to 0.27, p = 0.08, I2 = 67%). Importantly, no severe adverse events related to PTNS were reported in any of the participants. CONCLUSIONS Our meta-analysis revealed that PTNS was more effective than sham stimulation in reducing FI episodes and led to a higher proportion of patients reporting more than a 50% reduction in weekly FI episodes.
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Affiliation(s)
- Can Luo
- Department of Gynecology and Obstetrics, West China Second Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Dongmei Wei
- Department of Gynecology and Obstetrics, West China Second Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Kaiyin Pang
- Department of Gynecology and Obstetrics, West China Second Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Ling Mei
- Department of Gynecology and Obstetrics, West China Second Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Yueyue Chen
- Department of Gynecology and Obstetrics, West China Second Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Xiaoyu Niu
- Department of Gynecology and Obstetrics, West China Second Hospital, Sichuan University, Chengdu, China.
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China.
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O’Connor A, Reynolds E, Molyneux C, Vasant DH, Sharma A, Faulkner G, McLaughlin J, Kiff E, Telford K. Percutaneous tibial nerve stimulation versus sacral nerve stimulation for the treatment of faecal incontinence. Front Surg 2024; 11:1303119. [PMID: 38357189 PMCID: PMC10864541 DOI: 10.3389/fsurg.2024.1303119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 01/15/2024] [Indexed: 02/16/2024] Open
Abstract
Introduction Faecal incontinence (FI) is a common condition with a significant impact on quality of life (QoL). Neuromodulation treatments delivered by members of the multidisciplinary team including sacral nerve stimulation (SNS) and percutaneous tibial nerve stimulation (PTNS) are options for FI refractory to conservative management. The aim of this study was to assess whether a successful treatment with one neuromodulation modality corresponds with success in the other. Methods A retrospective review of a prospectively managed neuromodulation database identified 15 patients who had undergone both PTNS and SNS. The definition of success of each treatment was a >50% improvement in any of The St. Mark's Incontinence Score, Manchester Health Questionnaire, or weekly faecal urgency or FI episodes. Results Complete data from 12 patients was available for assessment and PTNS was delivered as the first treatment in nine patients. Overall, seven patients (58%) had successful PTNS treatment, with 10 (83%) having a successful SNS trials. Of the seven patients who had successful PTNS treatment, six patients (85.4%) went on to have success with SNS. Of the five patients who failed PTNS, four (80%) went on to have SNS success. Five (71%) of those who had positive PTNS outcomes had permanent SNS implantation as their final treatment decision. Conclusion This study suggests that there is no clear relationship between successful PTNS treatment and an SNS trial period which may be explained by differing mechanisms of action or the potential placebo effect of PTNS. Further work is required to investigate any association in larger studies to inform clinical practice.
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Affiliation(s)
- Alexander O’Connor
- Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Faculty of Biology, Medicine, and Health, The University of Manchester, Manchester, United Kingdom
| | - Elizabeth Reynolds
- Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Clare Molyneux
- Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Dipesh H. Vasant
- Neurogastroenterology Unit, Gastroenterology, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Division of Diabetes, Endocrinology and Gastroenterology, The University of Manchester, Manchester, United Kingdom
| | - Abhiram Sharma
- Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Faculty of Biology, Medicine, and Health, The University of Manchester, Manchester, United Kingdom
| | - Gemma Faulkner
- Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - John McLaughlin
- Division of Diabetes, Endocrinology and Gastroenterology, The University of Manchester and Manchester Academic Health Sciences Centre, Manchester, United Kingdom
| | - Edward Kiff
- Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Karen Telford
- Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Faculty of Biology, Medicine, and Health, The University of Manchester, Manchester, United Kingdom
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de Codes LMG, de Jesus ACC, de Codes JJG, Ferreira RF, da Silva Beda Sacramento C, da Cruz IDM, de Castro Ribeiro Fidelis F, de Carvalho AL, Motta MP, de Oliveira Alves C, Netto EM, Santana GO. Anorectal Function and Clinical Characteristics Associated with Faecal Incontinence in Patients with Crohn's Disease. J Crohns Colitis 2023; 17:1252-1261. [PMID: 36951290 DOI: 10.1093/ecco-jcc/jjad048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Indexed: 03/24/2023]
Abstract
BACKGROUND AND AIMS Faecal incontinence is an important complaint reported by patients with Crohn's disease [CD] and it is associated with several disease-related mechanisms, including anorectal functional disorders. This study aimed to assess the anorectal function and clinical characteristics to identify parameters associated with faecal incontinence in CD patients. METHODS This is a cross-sectional study of 104 patients with CD, aged 18 years or older, from a referral centre between August 2019 and May 2021. Patients responded to a specific questionnaire, and underwent medical record review, proctological examination and anorectal functional assessment with anorectal manometry. RESULTS Of the 104 patients, 49% were incontinent. Patients with incontinence had a lower mean resting pressure [43.5 vs 53.1 mmHg; p = 0.038], lower mean squeeze pressure [62.1 vs 94.1 mmHg; p = 0.036] and lower maximum rectal capacity [140 vs 180 mL; p < 0.001]. Faecal incontinence was also associated with disease activity [p < 0.001], loose stools [p = 0.02], perianal disease [p = 0.006], previous anoperineal surgery [p = 0.048] and number of anorectal surgeries [p = 0.036]. CONCLUSIONS This is the largest reported study describing manometric findings of Crohn's disease patients with and without faecal incontinence. Our results identified an association between faecal incontinence and functional disorders, in addition to clinical features in these patients. Functional assessment with anorectal manometry may help choose the best treatment for faecal incontinence in patients with CD.
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Affiliation(s)
- Lina Maria Góes de Codes
- Medicine and Health Science Postgraduate Program, Universidade Federal da Bahia, Salvador, Brazil; Department of Surgery, Hospital Universitário Professor Edgard Santos, Salvador, Brazil
| | | | | | | | | | | | | | | | - Marina Pamponet Motta
- Department of Gastroenterology, Hospital Universitário Professor Edgard Santos, Salvador, Brazil
| | | | - Eduardo Martins Netto
- Medicine and Health Science Postgraduate Program, Universidade Federal da Bahia, Salvador, Brazil
| | - Genoile Oliveira Santana
- Medicine and Health Science Postgraduate Program, Universidade Federal da Bahia, Salvador, Brazil; Department of Life Sciences, Universidade do Estado da Bahia, Salvador, Brazil
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Jin Q, Zhu Y, Yin P, Li X. Tibial nerve electrical stimulation for fecal incontinence: a systematic review and meta-analysis. Updates Surg 2022:10.1007/s13304-022-01444-w. [DOI: 10.1007/s13304-022-01444-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 12/11/2022] [Indexed: 12/23/2022]
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Ibáñez-Vera AJ, Mondéjar-Ros RM, Franco-Bernal V, Molina-Torres G, Diaz-Mohedo E. Efficacy of Posterior Tibial Nerve Stimulation in the Treatment of Fecal Incontinence: A Systematic Review. J Clin Med 2022; 11:jcm11175191. [PMID: 36079119 PMCID: PMC9457187 DOI: 10.3390/jcm11175191] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 08/27/2022] [Accepted: 08/30/2022] [Indexed: 11/16/2022] Open
Abstract
Fecal incontinence is a condition that carries high social stigmatization and a determining factor in the quality of life of the person who suffers from it. Its etiology is multifactorial and treatment includes surgical and conservative measures, including stimulation of the posterior tibial nerve. The aim of this review is to determine whether posterior tibial nerve stimulation (PTNS) is more effective than other treatments in reducing episodes of fecal incontinence in adults. A systematic review of randomized clinical trials that analyzed different approaches and comparisons with other treatments in adults without neurological or metabolic diseases was carried out, analyzing, fundamentally, the reduction of episodes of fecal incontinence. In general, a reduction in fecal incontinence episodes is observed in the experimental groups compared with the control groups, although these differences are not significant in most studies. The results regarding the effectiveness of PTNS in reducing episodes of fecal incontinence compared to other treatments are not entirely conclusive, although benefits are observed regarding the stimulation of sacral roots. More well-designed studies with a long-term follow-up of the results are needed so that the recommendation of this treatment can be generalized.
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Affiliation(s)
| | | | - Vanessa Franco-Bernal
- Physiotherapy of Pelvic Floor, Campus Teatinos, University of Malaga, 29071 Malaga, Spain
| | - Guadalupe Molina-Torres
- Department of Nursing Science, Physiotherapy and Medicine, University of Almeria, 04120 Almería, Spain
- Correspondence: ; Tel.: +34-950-214601
| | - Esther Diaz-Mohedo
- Department of Physiotherapy, Faculty of Health Sciences, Campus Teatinos, University of Malaga, 29071 Malaga, Spain
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Assmann SL, Keszthelyi D, Kleijnen J, Anastasiou F, Bradshaw E, Brannigan AE, Carrington EV, Chiarioni G, Ebben LDA, Gladman MA, Maeda Y, Melenhorst J, Milito G, Muris JWM, Orhalmi J, Pohl D, Tillotson Y, Rydningen M, Svagzdys S, Vaizey CJ, Breukink SO. Guideline for the diagnosis and treatment of Faecal Incontinence-A UEG/ESCP/ESNM/ESPCG collaboration. United European Gastroenterol J 2022; 10:251-286. [PMID: 35303758 PMCID: PMC9004250 DOI: 10.1002/ueg2.12213] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 02/02/2022] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION The goal of this project was to create an up-to-date joint European clinical practice guideline for the diagnosis and treatment of faecal incontinence (FI), using the best available evidence. These guidelines are intended to help guide all medical professionals treating adult patients with FI (e.g., general practitioners, surgeons, gastroenterologists, other healthcare workers) and any patients who are interested in information regarding the diagnosis and management of FI. METHODS These guidelines have been created in cooperation with members from the United European Gastroenterology (UEG), European Society of Coloproctology (ESCP), European Society of Neurogastroenterology and Motility (ESNM) and the European Society for Primary Care Gastroenterology (ESPCG). These members made up the guideline development group (GDG). Additionally, a patient advisory board (PAB) was created to reflect and comment on the draft guidelines from a patient perspective. Relevant review questions were established by the GDG along with a set of outcomes most important for decision making. A systematic literature search was performed using these review questions and outcomes as a framework. For each predefined review question, the study or studies with the highest level of study design were included. If evidence of a higher-level study design was available, no lower level of evidence was sought or included. Data from the studies were extracted by two reviewers for each predefined important outcome within each review question. Where possible, forest plots were created. After summarising the results for each review question, a systematic quality assessment using the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) approach was performed. For each review question, we assessed the quality of evidence for every predetermined important outcome. After evidence review and quality assessment were completed, recommendations could be formulated. The wording used for each recommendation was dependent on the level of quality of evidence. Lower levels of evidence resulted in weaker recommendations and higher levels of evidence resulted in stronger recommendations. Recommendations were discussed within the GDG to reach consensus. RESULTS These guidelines contain 45 recommendations on the classification, diagnosis and management of FI in adult patients. CONCLUSION These multidisciplinary European guidelines provide an up-to-date comprehensive evidence-based framework with recommendations on the diagnosis and management of adult patients who suffer from FI.
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Affiliation(s)
- Sadé L. Assmann
- Department of Surgery and Colorectal SurgeryMaastricht University Medical CentreMaastrichtThe Netherlands
- Division of Gastroenterology‐HepatologyDepartment of Internal MedicineMaastricht University Medical CentreMaastrichtThe Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM)Maastricht UniversityMaastrichtThe Netherlands
| | - Daniel Keszthelyi
- Division of Gastroenterology‐HepatologyDepartment of Internal MedicineMaastricht University Medical CentreMaastrichtThe Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM)Maastricht UniversityMaastrichtThe Netherlands
| | - Jos Kleijnen
- School for Oncology and Developmental Biology (GROW)Maastricht UniversityMaastrichtThe Netherlands
| | - Foteini Anastasiou
- 4rth TOMY – Academic Primary Care Unit Clinic of Social and Family MedicineUniversity of CreteHeraklionGreece
| | - Elissa Bradshaw
- Community Gastroenterology Specialist NurseRoyal Free HospitalLondonEnglandUK
| | | | - Emma V. Carrington
- Surgical Professorial UnitDepartment of Colorectal SurgerySt Vincent's University HospitalDublinIreland
| | - Giuseppe Chiarioni
- Division of Gastroenterology of the University of VeronaAOUI VeronaVeronaItaly
- Center for Functional GI and Motility DisordersUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | | | - Marc A. Gladman
- The University of AdelaideAdelaide Medical SchoolFaculty of Health & Medical SciencesAdelaideAustralia
| | - Yasuko Maeda
- Department of Surgery and Colorectal SurgeryWestern General HospitalEdinburghUK
| | - Jarno Melenhorst
- Department of Surgery and Colorectal SurgeryMaastricht University Medical CentreMaastrichtThe Netherlands
- School for Oncology and Developmental Biology (GROW)Maastricht UniversityMaastrichtThe Netherlands
| | | | - Jean W. M. Muris
- Department of General PracticeCare and Public Health Research InstituteMaastricht UniversityMaastrichtThe Netherlands
| | | | - Daniel Pohl
- Department of Gastroenterology and HepatologyUniversity Hospital ZurichZurichSwitzerland
- Department of Gastrointestinal SurgeryUniversity Hospital of North NorwayTromsøNorway
| | | | - Mona Rydningen
- Norwegian National Advisory Unit on Incontinence and Pelvic Floor HealthTromsøNorway
| | - Saulius Svagzdys
- Medical AcademyLithuanian University of Health SciencesClinic of Surgery Hospital of Lithuanian University of Health Sciences Kauno KlinikosKaunasLithuania
| | | | - Stephanie O. Breukink
- Department of Surgery and Colorectal SurgeryMaastricht University Medical CentreMaastrichtThe Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM)Maastricht UniversityMaastrichtThe Netherlands
- School for Oncology and Developmental Biology (GROW)Maastricht UniversityMaastrichtThe Netherlands
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Menees S, Chey WD. Fecal Incontinence: Pathogenesis, Diagnosis, and Updated Treatment Strategies. Gastroenterol Clin North Am 2022; 51:71-91. [PMID: 35135666 DOI: 10.1016/j.gtc.2021.10.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Fecal incontinence (FI) is defined as the involuntary loss or passage of solid or liquid stool in patients. FI is a common and debilitating condition in men and women. The incidence increases with age and also often goes unreported to health care providers. It is crucial that providers ask at-risk patients about possible symptoms. Evaluation and management is tailored to specific symptoms and characteristics of the incontinence. If conservative methods fail to improve symptoms, then other surgical options are considered, such as sacral nerve stimulation and anal sphincter augmentation. This review provides an update on current and future therapies.
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Affiliation(s)
- Stacy Menees
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine Health System, Ann Arbor, MI, USA; Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.
| | - William D Chey
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine Health System, Ann Arbor, MI, USA
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Managing motility disorders of the gastrointestinal segment and obesity through electrical stimulation. HEALTH AND TECHNOLOGY 2021. [DOI: 10.1007/s12553-021-00590-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Bharucha AE, Oblizajek NR. Translumbosacral Neuromodulation Therapy Is a Promising Option for Fecal Incontinence. Am J Gastroenterol 2021; 116:80-81. [PMID: 33273260 PMCID: PMC7775327 DOI: 10.14309/ajg.0000000000001069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 10/26/2020] [Indexed: 12/11/2022]
Abstract
ABSTRACT Fecal incontinence is a common symptom that can significantly impair quality of life. The treatment options range from conservative measures (e.g., Kegel exercises, pelvic floor biofeedback therapy, fiber supplementation, or medications) to noninvasive nerve stimulation (e.g., posterior tibial nerve stimulation and transcutaneous tibial nerve stimulation), implanted neurostimulation (i.e., sacral nerve stimulation), perianal injection of dextranomer, and anal sphincteroplasty. In this issue of the journal, a promising, uncontrolled study suggests that noninvasive, repetitive magnetic stimulation of the lumbosacral nerves significantly improved symptoms, increased anal squeeze pressure, and increased rectal compliance in patients with fecal continence. Sham-controlled studies are necessary to confirm these findings.
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Affiliation(s)
- Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
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10
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Updates in treating fecal incontinence in women. Curr Opin Obstet Gynecol 2020; 32:461-467. [PMID: 32925257 DOI: 10.1097/gco.0000000000000660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Fecal incontinence is a chronic condition that can significantly affect a woman's quality of life. The pathogenesis of fecal incontinence is multifaceted and management ranges from supportive care, medical therapy to more invasive surgical procedures. This review will discuss the recent advancements in treating fecal incontinence. RECENT FINDINGS The pelvic floor disorder consortium has created a consensus document with recommendations on pelvic floor symptom measurement tools, patient-reported instruments, and questionnaires that should be used when evaluating fecal incontinence. There is new robust data reinforcing the importance of conservative management prior to proceeding with more invasive treatment. Lastly, several novel therapies that were developed in the past decade now have longer term data on safety and efficacy. SUMMARY Management of fecal incontinence is challenging, as no one therapy has been proven to be predominately effective. We should continue to first optimize patients with conservative therapy followed by induction of more advanced therapies. There needs to be continued efforts to develop and evaluate effective treatment guidelines and therapies for fecal incontinence.
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11
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Stanton AP, Chen AH. New options for managing fecal incontinence in women. JAAPA 2020; 33:50-52. [PMID: 32740116 DOI: 10.1097/01.jaa.0000684168.68881.61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Fecal incontinence often is underreported and can be associated with both social embarrassment and isolation. As patients often do not proactively discuss their symptoms, healthcare providers should screen for this distressing condition. The cause of fecal incontinence often is multifactorial, so no single therapy can guarantee perfect, risk-free outcomes. This article reviews the limited therapies for managing fecal incontinence, including a minimally invasive vaginal control device that may offer hope for managing fecal incontinence in women.
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Affiliation(s)
- Amanda P Stanton
- Amanda P. Stanton practices in the Department of Medical and Surgical Gynecology at Mayo Clinic in Jacksonville, Fla., and is an instructor of obstetrics and gynecology at Mayo Clinic College of Medicine and Science. Anita H. Chen is a consultant at Mayo Clinic in Florida and an assistant professor of obstetrics and gynecology at Mayo Clinic College of Medicine and Science. The authors have disclosed no potential conflicts of interest, financial or otherwise
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12
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D'Amico F, Wexner SD, Vaizey CJ, Gouynou C, Danese S, Peyrin-Biroulet L. Tools for fecal incontinence assessment: lessons for inflammatory bowel disease trials based on a systematic review. United European Gastroenterol J 2020; 8:886-922. [PMID: 32677555 DOI: 10.1177/2050640620943699] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Fecal incontinence is a disabling condition affecting up to 20% of women. OBJECTIVE We investigated fecal incontinence assessment in both inflammatory bowel disease and non-inflammatory bowel disease patients to propose a diagnostic approach for inflammatory bowel disease trials. METHODS We searched on Pubmed, Embase and Cochrane Library for all studies on adult inflammatory bowel disease and non-inflammatory bowel disease patients reporting data on fecal incontinence assessment from January 2009 to December 2019. RESULTS In total, 328 studies were included; 306 studies enrolled non-inflammatory bowel disease patients and 22 studies enrolled inflammatory bowel disease patients. In non-inflammatory bowel disease trials the most used tools were the Wexner score, fecal incontinence quality of life questionnaire, Vaizey score and fecal incontinence severity index (in 187, 91, 62 and 33 studies). Anal manometry was adopted in 41.2% and endoanal ultrasonography in 34.0% of the studies. In 142 studies (46.4%) fecal incontinence evaluation was performed with a single instrument, while in 64 (20.9%) and 100 (32.7%) studies two or more instruments were used. In inflammatory bowel disease studies the Wexner score, Vaizey score and inflammatory bowel disease quality of life questionnaire were the most commonly adopted tools (in five (22.7%), five (22.7%) and four (18.2%) studies). Anal manometry and endoanal ultrasonography were performed in 45.4% and 18.2% of the studies. CONCLUSION Based on prior validation and experience, we propose to use the Wexner score as the first step for fecal incontinence assessment in inflammatory bowel disease trials. Anal manometry and/or endoanal ultrasonography should be taken into account in the case of positive questionnaires.
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Affiliation(s)
- Ferdinando D'Amico
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston USA
| | | | - Célia Gouynou
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Silvio Danese
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
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Mazor Y, Prott GM, Sequeira C, Jones M, Ejova A, Kellow JE, Schnitzler M, Malcolm A. A novel combined anorectal biofeedback and percutaneous tibial nerve stimulation protocol for treating fecal incontinence. Therap Adv Gastroenterol 2020; 13:1756284820916388. [PMID: 32577132 PMCID: PMC7288816 DOI: 10.1177/1756284820916388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 03/09/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND/AIMS Fecal incontinence (FI) is a common, debilitating condition that causes major impact on quality of life for those affected. Non-surgical treatment options include anorectal biofeedback therapy (BF) and percutaneous tibial nerve stimulation (PTNS), usually performed separately. The aims of the current study were to determine the feasibility, tolerability, safety, and efficacy of performing a combined BF and PTNS treatment protocol. METHODS Female patients with urge FI were offered a novel pilot program combining BF with PTNS. The treatment protocol consisted of 13 weekly sessions: an educational session, followed by 5 combined BF and PTNS sessions, 6 PTNS and a final combined session. Anorectal physiology and clinical outcomes were assessed throughout the program. For efficacy, patients were compared with BF only historical FI patients matched for age, parity, and severity of symptoms. RESULTS A total of 12/13 (93%) patients completed the full program. Overall attendance rate was 93% (157/169 sessions). Patient comfort score with treatment was rated high at 9.8/10 (SD 0.7) for PTNS and 8.6/10 (SD 1.7) for the BF component. No major side effects were reported. A reduction of at least 50% in FI episodes/week was achieved by 58% of patients by visit 6, and 92% by visit 13. No physiology changes were evident immediately following PTNS compared with before, but pressure during sustained anal squeeze improved by the end of the treatment course. Comparing outcomes with historical matched controls, reductions in weekly FI episodes were more pronounced in the BF only group at visit 6, but not week 13. CONCLUSIONS In this pilot study, concurrent PTNS and anorectal biofeedback therapy has been shown to be feasible, comfortable, and low risk. The combined protocol is likely to be an effective treatment for FI, but future research could focus on optimizing patient selection.
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Affiliation(s)
| | - Gillian M. Prott
- Department of Gastroenterology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Carol Sequeira
- Department of Gastroenterology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Michael Jones
- Psychology Department, Macquarie University, Sydney, NSW, Australia
| | - Anastasia Ejova
- Psychology Department, Macquarie University, Sydney, NSW, Australia
| | - John E. Kellow
- Department of Gastroenterology, Royal North Shore Hospital, St Leonards, NSW, Australia,Kolling Institute of Medical Research, Sydney, NSW, Australia,Northern Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Margaret Schnitzler
- Department of Colorectal Surgery, Royal North Shore Hospital, St Leonards, NSW, Australia,Kolling Institute of Medical Research, Sydney, NSW, Australia,Northern Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Allison Malcolm
- Department of Gastroenterology, Royal North Shore Hospital, St Leonards, NSW, Australia,Kolling Institute of Medical Research, Sydney, NSW, Australia,Northern Clinical School, The University of Sydney, Sydney, NSW, Australia
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14
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Southwell BR. Electro‐Neuromodulation for Colonic Disorders—Review of Meta‐Analyses, Systematic Reviews, and RCTs. Neuromodulation 2020; 23:1061-1081. [DOI: 10.1111/ner.13099] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 10/30/2019] [Accepted: 12/11/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Bridget R. Southwell
- Surgical Research Group Murdoch Children's Research Institute Melbourne Australia
- Department of Urology Royal Children's Hospital Melbourne Australia
- Department of Paediatrics University of Melbourne Melbourne Australia
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15
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Tan K, Wells CI, Dinning P, Bissett IP, O'Grady G. Placebo Response Rates in Electrical Nerve Stimulation Trials for Fecal Incontinence and Constipation: A Systematic Review and Meta-Analysis. Neuromodulation 2019; 23:1108-1116. [PMID: 31889364 DOI: 10.1111/ner.13092] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 11/26/2019] [Accepted: 11/26/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Successful treatments following electrical nerve stimulation have been commonly reported in patients with fecal incontinence and constipation. However, many of these nerve stimulation trials have not implemented sham controls, and are, therefore, unable to differentiate overall treatment responses from placebo. This systematic review aimed to quantify placebo effects and responses following sham electrical nerve stimulation in patients with fecal incontinence and constipation. MATERIAL AND METHODS A literature search of Ovid MEDLINE, PubMed, EMBASE, and Cochrane databases was conducted from inception to April 2017. Randomized sham-controlled trials investigating the effect of lower gastrointestinal electrical nerve stimulation in fecal incontinence and constipation were included. Pediatric and non-sham controlled trials were excluded. RESULTS Ten randomized sham-controlled trials were included. Sham stimulation resulted in improvements in fecal incontinence episodes by 1.3 episodes per week (95% CI -2.53 to -0.01, p = 0.05), fecal urgency by 1.5 episodes per week (CI -3.32 to 0.25, p = 0.09), and Cleveland Clinic Severity scores by 2.2 points (CI 1.01 to 3.36, p = 0.0003). Sham also improved symptoms of constipation with improved stool frequency (1.3 episodes per week, CI 1.16 to 1.42, p < 0.00001), Wexner Constipation scores (5.0 points, CI -7.45 to -2.54 p < 0.0001), and Gastrointestinal Quality of Life scores (7.9 points, CI -0.46 to 16.18, p = 0.06). CONCLUSIONS Sham stimulation is associated with clinical and statistically meaningful improvements in symptoms of fecal incontinence and constipation, as well as quality of life scores, highlighting the importance of sham controls in nerve stimulation trials. Noncontrolled studies should be interpreted with caution.
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Affiliation(s)
- Kirin Tan
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Cameron I Wells
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Phil Dinning
- Departments of Surgery and Gastroenterology, Flinders Medical Centre, Flinders University, Adelaide, SA, Australia
| | - Ian P Bissett
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Gregory O'Grady
- Department of Surgery, University of Auckland, Auckland, New Zealand
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Solon JG, Waudby P, O'Grady H. Percutaneous tibial nerve stimulation can improve symptoms and quality of life in selected patients with faecal incontinence - A single-centre 5-year clinical experience. Surgeon 2019; 18:154-158. [PMID: 31699593 DOI: 10.1016/j.surge.2019.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 07/24/2019] [Accepted: 08/18/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Faecal incontinence is a debilitating condition that affects a significant proportion of the population. Conservative management remains the mainstay of treatment but surgical intervention such as neuromodulation can be indicated in cases refractory to medical therapy. AIM The aim of this study was to review the outcomes of patients who underwent percutaneous tibial nerve stimulation (PTNS) for faecal incontinence and urgency in a single institution over five years. RESULTS Eighty-one patients completed the 12-week trial of PTNS with a success rate of 80% (n = 64/81). Rates of faecal incontinence and urgency were reduced from 13 episodes per fortnight to 3 and from 10 to 3 respectively. Over a median follow up of 2 years (range 0-5 years) reduction in rates of faecal urgency and incontinence were maintained. Quality of life parameters were measured using a variety of established questionnaires. Improvements were observed in the majority of parameters that were maintained throughout the follow up period. CONCLUSION Percutaneous tibial nerve stimulation is one of the forms of neuromodulation available for the treatment of faecal incontinence and urgency in patients who failed conservative management. This study has shown that in carefully selected, motivated patients, the use of PTNS in conjunction with regular counseling from a specialist practitioner in pelvic floor disorders can improve both the symptoms and quality of life of patients with faecal urgency and mild faecal incontinence with improvements in symptomology maintained for up to 5 years.
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Affiliation(s)
- J G Solon
- Department of Colorectal Surgery, Castle Hill Hospital, HU16 5JQ, England, United Kingdom
| | - P Waudby
- Department of GI Physiology, Castle Hill Hospital, HU16 5JQ, England, United Kingdom
| | - H O'Grady
- Department of Colorectal Surgery, Castle Hill Hospital, HU16 5JQ, England, United Kingdom; Department of GI Physiology, Castle Hill Hospital, HU16 5JQ, England, United Kingdom.
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17
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Rodríguez Carrillo R, Ruiz Carmona MD, Alós Company R, Frangi Caregnato A, Alarcón Iranzo M, Solana Bueno A, Lozoya Trujillo R, García-Granero Ximénez E. Evaluation of the anorectal motor response after percutaneous stimulation of the posterior tibial nerve in patients with fecal incontinence. Tech Coloproctol 2019; 23:987-992. [PMID: 31538295 DOI: 10.1007/s10151-019-02092-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 09/12/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND The effect of posterior tibial nerve stimulation (PTNS) on the mechanisms of anal continence has not been fully demonstrated. The aim of this study was to assess the anal manometric response after percutaneous PTNS in patients with fecal incontinence (FI). METHODS This was a prospective study in patients with FI undergoing 1 weekly session of percutaneous PTNS for 8 weeks. A clinical assessment (Wexner scale) and a complete study of up to 22 manometric parameters were carried out prior to treatment and 2-4 weeks after the end of treatment. RESULTS A total of 32 patients were evaluated. After therapy, there was a decrease in the average Wexner score [12.6 (± 5.2) to 9.5 (± 5.2) (P < 0.005)] and an increase in the "anal canal length at rest" [4.55 (± 0.60) to 4.95 (± 0.21) P = 0.004], without observing variations in other manometric parameters. The decrease in the Wexner score was significantly correlated with an increase in the "pressure at 5 cm at rest" after therapy (r = 0.464 P = 0.030). CONCLUSIONS In our study, PTNS was associated with a significant decrease in the Wexner score and with an increase in the functional length of the anal canal at rest. The improvement in the Wexner scale was correlated with an increase in pressure at rest in the theoretical area of the anorectal junction.
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Affiliation(s)
- R Rodríguez Carrillo
- Servicio de Cirugía General y del Aparato Digestivo, Hospital de Sagunto, Valencia, Spain.
| | - M D Ruiz Carmona
- Servicio de Cirugía General y del Aparato Digestivo, Hospital de Sagunto, Valencia, Spain
| | - R Alós Company
- Servicio de Cirugía General y del Aparato Digestivo, Hospital de Sagunto, Valencia, Spain
| | - A Frangi Caregnato
- Servicio de Cirugía General y del Aparato Digestivo, Hospital de Sagunto, Valencia, Spain
| | - M Alarcón Iranzo
- Servicio de Cirugía General y del Aparato Digestivo, Hospital de Sagunto, Valencia, Spain
| | - A Solana Bueno
- Servicio de Cirugía General y del Aparato Digestivo, Hospital de Sagunto, Valencia, Spain
| | - R Lozoya Trujillo
- Servicio de Cirugía General y del Aparato Digestivo, Hospital de Sagunto, Valencia, Spain
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18
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Da Silva G, Sirany A. Recent advances in managing fecal incontinence. F1000Res 2019; 8. [PMID: 31448087 PMCID: PMC6676508 DOI: 10.12688/f1000research.15270.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/09/2019] [Indexed: 11/20/2022] Open
Abstract
Fecal incontinence (FI) is the uncontrolled passage of feces or gas in an individual who previously had control. The prevalence of the problem varies but can be as high as 50% of institutionalized individuals. The severity varies among individuals, but the negative impact on self-esteem and quality of life can have devastating effects. The goals of treatment are to decrease the frequency and severity of episodes as well as to improve quality of life. At present, several therapies, ranging from medical management to more invasive surgical interventions, are offered for the management of FI. In this article, we review the most recent advances in the management of FI.
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Affiliation(s)
- Giovanna Da Silva
- Department of Colon and Rectal Surgery, Cleveland Clinic Florida, Weston, FL, 33331, USA
| | - Anne Sirany
- Department of Colon and Rectal Surgery, Cleveland Clinic Florida, Weston, FL, 33331, USA
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Simillis C, Lal N, Pellino G, Baird D, Nikolaou S, Kontovounisios C, Smith JJ, Tekkis PP. A systematic review and network meta-analysis comparing treatments for faecal incontinence. Int J Surg 2019; 66:37-47. [PMID: 31022519 DOI: 10.1016/j.ijsu.2019.04.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 03/24/2019] [Accepted: 04/16/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although numerous treatments exist for fecal incontinence (FI), no consensus exists on the best treatment strategy. The aim was to review the literature and to compare the clinical outcomes and effectiveness of treatments available for FI. MATERIALS AND METHOD A systematic literature review was performed, from inception to May 2018, of the following databases: MEDLINE, EMBASE, Science Citation Index Expanded, Cochrane Library. The search terms used were "faecal incontinence" and "treatment". Only randomized controlled trials (RCTs) comparing treatments for FI were considered. A Bayesian network meta-analysis was performed using the Markov chain Monte Carlo method. RESULT Forty-seven RCTs were included comparing 37 treatments and reporting on 3748 participants. No treatment ranked best or worst with high probability for any outcome of interest. No significant difference was identified between treatments for frequency of FI per week, or in changing the resting pressure, maximum resting pressure, squeeze pressure, and maximum squeeze pressure. Radiofrequency resulted in more adverse events compared to placebo. Sacral nerve stimulation (SNS) and zinc-aluminium improved the fecal incontinence quality of life questionnaire (FIQL) lifestyle, coping, and embarrassment domains compared to placebo. Transcutaneous posterior tibial nerve stimulation (TPTNS) improved the FIQL embarrassment domain compared to placebo. Autologous myoblasts and zinc-aluminium improved the FIQL depression domain compared to placebo. SNS, artificial bowel sphincter (ABS), and zinc-aluminium significantly improved incontinence scores compared to placebo. Injection of non-animal stabilized hyaluronic acid/dextranomer (NASHA/Dx) resulted in more patients with ≥50% reduction in FI episodes compared to placebo. CONCLUSION SNS, ABS, TPTNS, NASHA/Dx, zinc-aluminium, and autologous myoblasts resulted in isolated improvements in specific outcomes of interest. No difference was identified in incontinence episodes, no treatment ranked best persistently or persistently improved outcomes, and many included treatments did not significantly benefit patients compared to placebo. Large multicentre RCTs with long-term follow-up and standardized inclusion criteria and outcome measures are needed.
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Affiliation(s)
- Constantinos Simillis
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK; Department of Surgery and Cancer, Imperial College, London, UK.
| | - Nikhil Lal
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK; Department of Surgery and Cancer, Imperial College, London, UK
| | - Gianluca Pellino
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Daniel Baird
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK; Department of Surgery and Cancer, Imperial College, London, UK
| | - Stella Nikolaou
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK; Department of Surgery and Cancer, Imperial College, London, UK
| | - Christos Kontovounisios
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK; Department of Surgery and Cancer, Imperial College, London, UK
| | - Jason J Smith
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK; Department of Surgery and Cancer, Imperial College, London, UK
| | - Paris P Tekkis
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK; Department of Surgery and Cancer, Imperial College, London, UK
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Dedemadi G, Takano S. Efficacy of Bilateral Transcutaneous Posterior Tibial Nerve Stimulation for Fecal Incontinence. Perm J 2019; 22:17-231. [PMID: 30028671 DOI: 10.7812/tpp/17-231] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
CONTEXT Posterior tibial nerve stimulation is a new second-line treatment for refractory fecal incontinence. OBJECTIVE To assess the efficacy of bilateral transcutaneous posterior tibial nerve stimulation (BTPTNS) for treatment of fecal incontinence in Japanese patients and its impact on quality of life. DESIGN A prospective observational-interventional study was conducted from May 2015 to June 2017 in patients with fecal incontinence in whom conservative treatment had failed. All patients received a 30-minute session of stimulation twice weekly for 6 consecutive weeks. Evaluation at baseline and at 6 weeks involved the Wexner score, Fecal Incontinence Quality of Life (FIQL) questionnaire, and anal manometry. Patients recorded episodes of incontinence in a weekly diary. MAIN OUTCOME MEASURES Reduction of 50% or greater in incontinence episodes, decreased Wexner score, and improved FIQL scores. RESULTS Twenty-two patients with a median age of 64.1 years (range, 26-81 years) and men:women ratio of 9:13 completed BTPTNS. Mean episodes of fecal incontinence were significantly reduced from 4.7 to 1.5 (p < 0.05). An improvement of 50% or better in episodes of fecal incontinence was achieved in 77.2% of patients. The median Wexner score significantly decreased from 10.2 to 6.9 (p < 0.05). The median FIQL score improved from 2.7 to 3.1 (p = 0.06), and significant improvement was seen in the embarrassment domain (2.2 vs 2.8, p < 0.05). Resting and squeezing anal pressures revealed no significant changes. CONCLUSION Our findings suggest that BTPTNS is safe and well tolerated and may improve symptoms of fecal incontinence. This technique offers an additional noninvasive, less expensive form of treatment.
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Affiliation(s)
- Georgia Dedemadi
- Surgeon in the Department of Functional Anorectal Disorders at Coloproctology Center Takano Hospital in Kumamoto City, Japan, and a Surgeon in the Department of Surgery at Sismanoglio-Amalia Fleming Hospital in Athens, Greece.
| | - Shota Takano
- Surgeon in the Department of Functional Anorectal Disorders at Coloproctology Center Takano Hospital in Kumamoto City, Japan.
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Medium-term outcome of percutaneous tibial nerve stimulation in the treatment of fecal incontinence. Tech Coloproctol 2018; 22:875-879. [PMID: 30565161 DOI: 10.1007/s10151-018-1892-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 11/20/2018] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Fecal incontinence (FI) is a multifactorial disease that affects patients' quality of life. The aim of this study was to evaluate the efficacy of posterior tibial nerve stimulation (PTNS) in the treatment of FI and to assess the medium-term results. METHODS A prospective cohort of patients with FI treated with PTNS between 2012 and 2014 was analysed. Endoluminal ultrasound and anorectal physiologic studies were performed in all patients. The efficacy of PTNS was assessed using a validated questionnaire (Cleveland Clinic Incontinence Score) at baseline, after treatment, and 2 years later. The Vaizey score was also used at 2-year follow-up to assess urge incontinence. RESULTS Fifty-six patients (38 females; mean age 59.7 years) with FI were treated. The causes of FI were mainly obstetric injury and previous colorectal surgery. A decrease of 50% from baseline CCIS was seen in 41.1% of patients after PTNS. One-third maintained a minimum of 50% decrease of their initial CCIS after 2 years. Comparing CCIS at baseline, after treatment, and at 2-year follow-up, a statistically significant difference was observed (p < 0.0001 and p < 0.0004 respectively). Medium-term improvement was not maintained in patients with passive and mixed FI, while it was maintained in those with urge incontinence. At 2 years, patients with mild incontinence maintained the greatest response. CONCLUSIONS PTNS is a safe, effective, non-invasive treatment for FI with good results in almost half of the patients at the end of the treatment. There is also an acceptable maintained response at 2-year follow-up. It seems to be most successful in patients with mild incontinence and urge incontinence.
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Hounsome N, Roukas C. Cost-effectiveness of sacral nerve stimulation and percutaneous tibial nerve stimulation for faecal incontinence. Therap Adv Gastroenterol 2018; 11:1756284818802562. [PMID: 30305847 PMCID: PMC6176537 DOI: 10.1177/1756284818802562] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 08/23/2018] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Subcutaneous sacral nerve stimulation is recommended by the United Kingdom (UK) National Institute for Health and Care Excellence (NICE) as a second-line treatment for patients with faecal incontinence who failed conservative therapy. Sacral nerve stimulation is an invasive procedure associated with complications and reoperations. This study aimed to investigate whether delivering less invasive and less costly percutaneous tibial nerve stimulation prior to sacral nerve stimulation is cost-effective. METHODS A decision analytic model was developed to estimate the cost-effectiveness of percutaneous tibial nerve stimulation with subsequent subcutaneous sacral nerve stimulation versus subcutaneous sacral nerve stimulation alone. The model was populated with effectiveness data from systematic reviews and cost data from randomized studies comparing both procedures in a UK National Health Service (NHS) setting. RESULTS Offering percutaneous tibial nerve stimulation prior to sacral nerve stimulation (compared with delivering sacral nerve stimulation straight away) was both more effective and less costly in all modeled scenarios. The estimated savings from offering percutaneous tibial nerve stimulation first were £662-£5,697 per patient. The probability of this strategy being cost-effective was around 80% at £20,000-£30,000 per quality-adjusted life-year (QALY). CONCLUSION Our analyses suggest that offering patients percutaneous tibial nerve stimulation prior to sacral nerve stimulation can be both cost-effective and cost-saving in the treatment of faecal incontinence.
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Affiliation(s)
| | - Chris Roukas
- Pragmatic Clinical Trials Unit, Queen Mary
University of London, London, UK
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Abstract
PURPOSE OF REVIEW The purpose of this review is to highlight current and newer therapeutic approaches to treat fecal incontinence in patients who do not respond to conservative measures. RECENT FINDINGS Neurostimulation techniques, injection of bulking agents, and radiofrequency energy delivery to the anal canal have been proposed and tested for fecal incontinence over the last decade. Sacral stimulation is both effective and durable and is now the most popular of the invasive techniques whereas percutaneous tibial stimulation, radiofrequency energy, and bulking agents are either less effective or their evaluation has been handicapped by suboptimal study designs. The precise indications for the new vaginal control device and anal plugs remain to be established. The magnetic anal sphincter is disappointing. Stem cell therapy is a potentially exciting approach, which is in its infancy. There continues to be an unmet need for innovative approaches to patients with fecal incontinence who do not respond to conservative measures. The efficacy of current and future therapies should be assessed using criteria more stringent than has been used in the past to provide a more realistic assessment of meaningful efficacy.
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