Fecal incontinence in Wisconsin nursing homes: prevalence and associations

The human colon: Evidence for degenerative changes during aging and the physiological consequences

BACKGROUND

The incidence of constipation increases among the elderly (>65 years), while abdominal pain decreases. Causes include changes in lifestyle (e.g., diet and reduced exercise), disease and medications affecting gastrointestinal functions. Degenerative changes may also occur within the colo-rectum. However, most evidence is from rodents, animals with relatively high rates of metabolism and accelerated aging, with considerable variation in time course. In humans, cellular and non-cellular changes in the aging intestine are poorly investigated.

PURPOSE

To examine all available studies which reported the effects of aging on cellular and tissue functions of human isolated colon, noting the region studied, sex and age of tissue donors and study size. The focus on human colon reflects the ability to access full-thickness tissue over a wide age range, compared with other gastrointestinal regions. Details are important because of natural human variability. We found age-related changes within the muscle, in the enteric and nociceptor innervation, and in the submucosa. Some involve all regions of colon, but the ascending colon appears more vulnerable. Changes can be cell- and sublayer-dependent. Mechanisms are unclear but may include development of "senescent-like" and associated inflammaging, perhaps associated with increased mucosal permeability to harmful luminal contents. In summary, reduced nociceptor innervation can explain diminished abdominal pain among the elderly. Degenerative changes within the colon wall may have little impact on symptoms and colonic functions, because of high "functional reserve," but are likely to facilitate the development of constipation during age-related challenges (e.g., lifestyle, disease, and medications), now operating against a reduced functional reserve.

Global Prevalence of Fecal Incontinence in Community-Dwelling Adults: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

Fecal incontinence (FI) can considerably impair quality of life. Through a systematic review and meta-analysis, we sought to determine the global prevalence and geographic distribution of FI and to characterize its relationship with sex and age.

METHODS

We searched PubMed, Web of Science, and Cochrane Library databases to identify population-based surveys of the prevalence of FI.

RESULTS

Of the 5175 articles identified, the final analysis included 80 studies; the median response rate was 66% (interquartile range [IQR], 54%-74%). Among 548,316 individuals, the pooled global prevalence of FI was 8.0% (95% confidence interval [CI], 6.8%-9.2%); by Rome criteria, it was 5.4% (95% CI, 3.1%-7.7%). FI prevalence was greater for persons aged 60 years and older (9.3%; 95% CI, 6.6%-12.0%) compared with younger persons (4.9%; 95% CI, 2.9%-6.9%) (odds ratio [OR], 1.75; 95% CI, 1.39-2.20), and it was more prevalent among women (9.1%; 95% CI, 7.6%-10.6%) than men (7.4%; 95% CI, 6.0%-8.8%]) (OR, 1.17; 95% CI, 1.06-1.28). The prevalence was highest in Australia and Oceania, followed by North America, Asia, and Europe, but prevalence could not be estimated in Africa and the Middle East. The risk of bias was low, moderate, and high for 19 (24%), 46 (57%), and 15 (19%) studies, respectively. Exclusion of studies with high risk of bias did not affect the prevalence of FI or heterogeneity. In the meta-regression, the high study heterogeneity (I2 = 99.61%) was partly explained by age.

CONCLUSIONS

Approximately 1 in 12 adults worldwide have FI. The prevalence is greater among women and older people.

[Urinary incontinence]

Prevalence and incidence of both urinary and fecal incontinence increase with age. They reduce everyday competence and quality of life in all age groups. It is often not recognized because those affected do not express their complaints, but even if the diagnosis has been made, therapy and care often remains inadequate. The aim of the article is to know types of incontinence and their treatment options for a maximum of continence according to the established continence profiles. In older, especially multimorbid frail people, urinary incontinence is not primarily to be seen as a symptom of a disease, but as a "geriatric syndrome". In the interplay of multimorbidity, environmental factors and other contextual factors that can influence each other, this must be taken into account in diagnostics and therapy. Incontinence itself leads to increased immobility, thus to falls in the elderly and to mental impairments.

Fecal Incontinence: Pathogenesis, Diagnosis, and Updated Treatment Strategies

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.

ACG Clinical Guidelines: Management of Benign Anorectal Disorders

Benign anorectal disorders of structure and function are common in clinical practice. These guidelines summarize the preferred approach to the evaluation and management of defecation disorders, proctalgia syndromes, hemorrhoids, anal fissures, and fecal incontinence in adults and represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence for these guidelines was assessed using the Grading of Recommendations Assessment, Development and Evaluation process. When the evidence was not appropriate for Grading of Recommendations Assessment, Development and Evaluation, we used expert consensus to develop key concept statements. These guidelines should be considered as preferred but are not the only approaches to these conditions.

What Is Fecal Incontinence That Urologists Need to Know?

Fecal incontinence (FI) undoubtedly reduces quality of life and adversely affects the social life of the affected individual. FI has a higher prevalence with age and has an equivalent prevalence to urinary incontinence in patients with genitourinary disease, but is often not confirmed in these cases. A thorough investigation is needed to diagnose FI, with the common etiology of this condition in mind, and several questionnaires can be used to identify symptoms. The physical examination contains digital rectal examination carries out to identify the patient's condition. Ultrasound, colonoscopy, and rectum pressure test can be performed. Patients educated in diet-related issues, bowel movements, and defecation mechanism. Nonoperative options such as diet control and Kegel exercise should be performed at first. Surgical treatment of FI is considered when conservative management and oral medications produce no improvement. Surgical options include less invasive procedures like bulking agent injections, and more involved approaches from sacral nerve stimulation to invasive direct sphincter repair and artificial bowel sphincter insertion. Good outcomes in FI cases have also recently been reported for barrier devices.

Fecal Incontinence in the Elderly

Fecal incontinence can be a challenging and stigmatizing disease with a high prevalence in the elderly population. Despite effective treatment options, most patients do not receive care. Clues in the history and physical examination can assist the provider in establishing the diagnosis. Direct inquiry about the presence of incontinence is key. Bowel disturbances are common triggers for symptoms and represent some of the easiest treatment targets. We review the epidemiology and impact of the disease, delineate a diagnostic and treatment approach for primary care physicians to identify patients with suspected fecal incontinence and describe appropriate treatment options.

Japanese Practice Guidelines for Fecal Incontinence Part 1-Definition, Epidemiology, Etiology, Pathophysiology and Causes, Risk Factors, Clinical Evaluations, and Symptomatic Scores and QoL Questionnaire for Clinical Evaluations-English Version

Fecal incontinence (FI) is defined as involuntary or uncontrollable loss of feces. Gas incontinence is defined as involuntary or uncontrollable loss of flatus, while anal incontinence is defined as the involuntary loss of feces or flatus. The prevalence of FI in people over 65 in Japan is 8.7% in the male population and 6.6% among females. The etiology of FI is usually not limited to one specific cause, with risk factors for FI including physiological factors, such as age and gender; comorbidities, such as diabetes and irritable bowel syndrome; and obstetric factors, such as multiple deliveries, home delivery, first vaginal delivery, and forceps delivery. In the initial clinical evaluation of FI, the factors responsible for individual symptoms are gathered from the history and examination of the anorectal region. The evaluation is the basis of all medical treatments for FI, including initial treatment, and also serves as a baseline for deciding the need for a specialized defecation function test and selecting treatment in stages. Following the general physical examination, together with history taking, inspection (including anoscope), and palpation (including digital anorectal and vaginal examination) of the anorectal area, clinicians can focus on the causes of FI. For the clinical evaluation of FI, it is useful to use Patient-Reported Outcome Measures (PROMs), such as scores and questionnaires, to evaluate the symptomatic severity of FI and its influence over quality of life (QoL).

Study of defecation disorders in elderly patients

Introduction Defecation disorders, whether anal incontinence or chronic intestinal constipation, are frequent pelvic floor alterations in the general population and are more common in those with risk factors,i.e., in the elderly, women with an obstetric background, and those with comorbidities, history of pelvic radiotherapy, diabetics, the bedridden, or those with history of orifice surgery, among others.

Objective To analyze the incidence of defecation disorders in geriatric patients treated at the Medical Specialties Outpatient Service (MSOS) of Hospital Santa Marcelina.

Methods Prospective, randomized study that interviewed the same patients in two moments: 1) subjective anamnesis through spontaneous history and 2) objective anamnesis with specific questionnaires to assess anal incontinence and chronic constipation.

Results Between March 2016 and June 2017, 149 patients were analyzed, of whom 114 (76.5%) were female, with a similar mean age between genders; 51.67% had symptoms of anal incontinence and/or chronic constipation. Only 35.5% of patients with complaints of fecal leakage or flatus spontaneously reported them, while 87.1% of constipated patients did so. In the present study, no significant correlation was observed between the mode of delivery (p = 0.106), pregnancy (p = 0.099), and the number of deliveries (p = 0.126) with anal incontinence. In turn, there was no higher incidence of chronic intestinal constipation in females (p = 0.099) and most patients with this complaint had Bristol type 1 or 2 stools.

Conclusion The incidence of defecation disorders in the geriatric population is high and, most notably, anal incontinence is not spontaneously reported by most patients.

Insert devices for faecal incontinence

BACKGROUND

Faecal incontinence (FI) affects 1-19% of the general population and carries significant physical and psychological morbidity. Treatment strategies vary greatly with respect to morbidity and efficacy and relatively little is known regarding the role of mechanical devices such as anal and vaginal inserts. This is an up-to-date systematic review of the use of these devices in the management of patients with FI.

METHODS

A systematic electronic search was performed of the Medline, Pubmed and Embase databases using the key words and/or MeSH 'anal plug', 'anal insert', 'vaginal insert' and 'faecal incontinence'. Only articles that reported clinical outcomes for these devices for FI in the English language were included. Review articles were excluded to avoid duplication of data.

RESULTS

Thirteen articles fulfilled the eligibility criteria. Two articles reported outcomes for the Eclipse vaginal insert and 11 articles reported on three types of anal inserts; the Coloplast 'Tulip' design (6), the Procon/ProTect device (2) and the Renew insert (3). When tolerated, both anal and vaginal inserts significantly improved continence, bowel function and quality of life where reported. Adverse effects included discomfort, leakage and slippage. Long-term compliance and benefit are yet to be determined.

CONCLUSIONS

Vaginal and anal inserts may be a useful treatment for FI. Better quality of evidence is needed to define its effectiveness.

Constipation and Fecal Incontinence in the Elderly

PURPOSE OF REVIEW

To review the epidemiology, pathogenesis, clinical features, and management of primary constipation and fecal incontinence in the elderly.

RECENT FINDINGS

Among elderly people, 6.5%, 1.7%, and 1.1% have functional constipation, constipation-predominant IBS, and opioid-induced constipation. In elderly people, the number of colonic enteric neurons and smooth muscle functions is preserved; decreased cholinergic function with unopposed nitrergic relaxation may explain colonic motor dysfunction. Less physical activity or dietary fiber intake and postmenopausal hormonal therapy are risk factors for fecal incontinence in elderly people. Two thirds of patients with fecal incontinence respond to biofeedback therapy. Used in combination, loperamide and biofeedback therapy are more effective than placebo, education, and biofeedback therapy. Vaginal or anal insert devices are another option. In the elderly, constipation and fecal incontinence are common and often distressing symptoms that can often be managed by addressing bowel disturbances. Selected diagnostic tests, prescription medications, and, infrequently, surgical options should be considered when necessary.

Prevalence and Severity of Fecal Incontinence in Veterans

Background/Aims

Fecal incontinence (FI) is a common complaint that increases in prevalence with age. Our aim was to determine the prevalence of FI and assess its severity by self-report in a male-predominant Veteran outpatient clinic setting.

Methods

An anonymous 28 item questionnaire was administered to a convenience sample of veterans awaiting appointments. FI was defined as a loss of liquid or solid stool at least monthly. Multivariable logistic and linear models were used to identify predictors of FI prevalence and severity.

Results

One hundred thirty-three gastroenterology (GI) participants and 126 primary care (PC) participants completed the survey. Ninety-four of 259 participants (36.3%, 95% confidence interval [CI]: 30.4–42.5) reported an episode of FI (41.4% GI participants vs 31.0% PC participants; P = 0.078) with 33.6% having FI within the last 30 days (36.8% GI participants vs 30.2% PC participants; P = 0.122). Participants with more bowel movements per week (P = 0.005) and per day (P < 0.001) and with a higher Bristol Stool Scale form (P = 0.010) were more likely to have FI. Of participants with FI, mean Fecal Incontinence Severity Index score was 23.0 ± 9.5 with a significantly higher symptom score in GI participants compared to PC participants (25.2 ± 10.0 vs 20.1 ± 8.2; P = 0.011). Few participants had ever been asked by (35.0%) or evaluated by (18.0%) a doctor for FI symptoms.

Conclusions

FI is a common complaint and under-recognized problem in the male-dominant Veteran population. Despite its prevalence, relatively few participants were asked about FI, with even less being treated. Due to the possible effects and implications on quality of life, more should be done to recognize this condition and arrange treatment.

Cesarean delivery to prevent anal incontinence: a systematic review and meta-analysis

BACKGROUND

Cesarean delivery (CD), is increasingly recommended as a mode of delivery that prevents the anal incontinence (AI) that arises in some women after vaginal delivery (VD). The assessment of the efficacy of CD in this regard was the subject of this systematic review.

METHODS

Searches were conducted in Medline, EMBASE and the Cochrane Library. Both randomized (RCTs) and non-randomized trials (NRTs) comparing the risk of sustained fecal and/or flatus incontinence after VD or CD were sought from 1966 to 1 January, 2019. Studies were eligible if they assessed AI more than 6 months after birth, and had statistical adjustment for at least one of the three major confounders for AI: age, maternal weight or parity. In addition, each study was required to contain more than 250 participants, more than 50 CDs and more than 25 cases of AI. Data after screening and selection were abstracted and entered into Revman for meta-analysis. Analyses were done for combined fecal and flatus incontinence (comAI), fecal incontinence (FI), gas incontinence (GI), CD before or during labor, time trend of incontinence after delivery, assessment of both statistical and clinical heterogeneity, parity and late incident AI.

RESULTS

Out of the 2526 titles and abstracts found, 24 eligible studies were analyzed, 23 NRTs and one RCT. These included women with 29,597 VDs and women with 6821 CDs. Among the primary outcomes, VD was found not to be a significant predictor of postpartum comAI compared to CD in 6 studies, incorporating 18,951 deliveries (OR = 0.74; 0.54-1.02). VD was also not a significant predictor of FI in 14 studies, incorporating 29,367 deliveries, (OR = 0.89; 0.76-1.05). VD was not a significant predictor of GI in six studies, incorporating 6724 deliveries (OR = 0.96; 0.79-1.18). The strength of the grading of recommendations, assessment, development and evaluations (GRADE) evidence for each of these was low for comAI and moderate for FI and GI (upgrade for lack of expected effect). Time trend FI showed incontinence at 3 months often resolved at 1 year. Other secondary analyses assessing parity, delayed incidence of FI, clinical and statistical heterogeneity, spontaneous VD only, late risk of incidence of AI, and CD in or prior to labor all had similar results as in the primary outcomes.

CONCLUSIONS

There are three components of pelvic floor dysfunction that are thought to be caused by VD and hopefully prevented by CD: AI, urinary incontinence and pelvic floor prolapse. Of these, AI was not found to be reliably prevented by CD in this review.

Mechanical inserts for the treatment of faecal incontinence: A systematic review

Objective: To perform a systematic review of the literature to examine original research on the role of mechanical inserts, both vaginal and anal, for the treatment of faecal incontinence (FI).

Materials and methods: We searched the PubMed, Cochrane Library, and ClinicalTrials.gov databases for any peer-reviewed original research in English on the role of mechanical inserts for the treatment of FI.

Results: We identified 35 unique citations. After title review and exclusion of articles not reporting original research, eight publications were included in the final review: two focused on vaginal inserts and six focused on anal inserts. Limited evidence indicates that both vaginal and anal inserts can be an effective and safe therapeutic option for patients with FI.

Conclusions: Data regarding vaginal and anal mechanical inserts for the treatment of FI, albeit limited, suggest that inserts can be included in a discussion of therapeutic options for a patient with FI. Further studies are needed to elucidate long-term usability, efficacy, and safety.

Abbreviations: FI: faecal incontinence; (m)ITT: (modified) intention-to-treat

The Prevalence, Incidence, and Correlates of Fecal Incontinence Among Older People Residing in Care Homes: A Systematic Review

OBJECTIVE

Older people resident in care homes often rely on staff for support relating to their activities of daily living, including intimate care such as continence care. Managing fecal incontinence can be challenging for both residents and care staff. We conducted this review to describe the prevalence, incidence, and correlates of fecal incontinence among care home residents.

DESIGN

Systematic literature review.

SETTING AND PARTICIPANTS

Older care home residents (both nursing and residential care) aged 60 years and older.

MEASURES

We defined double incontinence as the presence of fecal plus urinary incontinence, isolated fecal incontinence as fecal incontinence with no urinary incontinence, and all fecal incontinence as anyone with fecal incontinence (whether isolated or double). The CINAHL and MEDLINE databases were searched up to December 31, 2017, to retrieve all studies reporting the prevalence and/or incidence and correlates of fecal incontinence.

RESULTS

We identified 278 citations after removing duplicates, and 23 articles met the inclusion criteria. There were 12 high-quality studies, 5 medium-quality studies, and 6 low-quality studies. The medians for prevalence (as reported by the studies) of isolated fecal incontinence, double incontinence, and all fecal incontinence were 3.5% [interquartile range (IQR) = 2.8%], 47.1% (IQR = 32.1%), and 42.8% (IQR = 21.1%), respectively. The most frequently reported correlates of fecal incontinence were cognitive impairment, limited functional capacity, urinary incontinence, reduced mobility, advanced age, and diarrhea.

CONCLUSIONS/IMPLICATIONS

Fecal incontinence is prevalent among older people living in care homes. Correlates included impaired ability to undertake activities of daily living, reduced mobility, laxative use, and altered stool consistency (eg, constipation or diarrhea) which are potentially amenable to interventions to improve fecal incontinence.

Managing Faecal INcontinence in people with advanced dementia resident in Care Homes (FINCH) study: a realist synthesis of the evidence

BACKGROUND

Eighty per cent of care home residents in the UK are living with dementia. The prevalence of faecal incontinence (FI) in care homes is estimated to range from 30% to 50%. There is limited evidence of what is effective in the reduction and management of FI in care homes.

OBJECTIVE

To provide a theory-driven explanation of the effectiveness of programmes that aim to improve FI in people with advanced dementia in care homes.

DESIGN

A realist synthesis. This was an iterative approach that involved scoping of the literature and consultation with five stakeholder groups, a systematic search and analysis of published and unpublished evidence, and a validation of programme theories with relevant stakeholders.

DATA SOURCES

The databases searched included PubMed, Cumulative Index to Nursing and Allied Health Literature, The Cochrane Library, Scopus, SocAbs, Applied Social Sciences Index and Abstracts, BiblioMap, Sirius, OpenGrey, Social Care Online and the National Research Register.

RESULTS

The scoping identified six programme theories with related context-mechanism-outcome configurations for testing. These addressed (1) clinician-led support, assessment and review, (2) the contribution of teaching and support for care home staff on how to reduce and manage FI, (3) the causes and prevention of constipation, (4) how the cognitive and physical capacity of the resident affect outcomes, (5) how the potential for recovery, reduction and management of FI is understood by those involved and (6) how the care of people living with dementia and FI is integral to the work patterns of the care home and its staff. Data extraction was completed on 62 core papers with iterative searches of linked literature. Dementia was a known risk factor for FI, but its affect on the uptake of different interventions and the dementia-specific continence and toileting skills staff required was not addressed. Most care home residents with FI will be doubly incontinent and, therefore, there is limited value in focusing solely on FI or on single causes of FI such as constipation. Clinical assessment, knowledge of the causes of FI and strategies that recognise the individuals' preferences are necessary contextual factors. Valuing the intimate and personal care work that care home staff provide to people living with dementia and addressing the dementia-related challenges when providing continence care within the daily work routines are key to helping to reduce and manage FI in this population.

LIMITATIONS

The synthesis was constrained by limited evidence specific to FI and people with dementia in care homes and by the lack of dementia-specific evidence on continence aids.

CONCLUSIONS

This realist synthesis provides a theory-driven understanding of the conditions under which improvement in care for care home residents living with dementia and FI is likely to be successful.

FUTURE WORK

Future multicomponent interventions need to take account of how the presence of dementia affects the behaviours and choices of those delivering and receiving continence care within a care home environment.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42014009902.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

High-Resolution Anorectal Manometry - New Insights in the Diagnostic Assessment of Functional Anorectal Disorders

Functional anorectal disorders such as faecal incontinence (FI), functional anorectal pain, and functional defecation disorders (FDD) are highly prevalent and represent a high socioeconomic burden. Several tests of anorectal function exist in this setting; however, high-resolution anorectal manometry (HR-ARM) is a new tool that depicts pressure all along the anal canal and can assess rectoanal coordination. HR-ARM is used in the diagnosis of FI and especially FDD although data in health is still sparse, and pressure phenomena seen during simulated defecation, such as dyssynergia, are highly prevalent in health.

Age and Dyssynergia Subtypes Associated With Normal Sphincter Pressures in Women With Fecal Incontinence

OBJECTIVES

Fecal incontinence (FI) is frequently associated with low sphincter pressures, sensory abnormalities, and advanced age. Twenty-three percent of patients with FI and 22% of healthy patients demonstrate dyssynergic defecation (DD) on high-resolution anorectal manometry. Overflow incontinence occurs in some DD patients with normal resting and squeeze anal sphincter pressures. Our aim was to identify factors associated with normal sphincter pressures in women with FI.

METHODS

We reviewed medical records of 134 women with FI. Patients with normal resting and squeeze anal pressures were compared with those with abnormal pressures using Wilcoxon rank sum test and Fisher exact. Multivariable logistic regression was performed to identify factors associated with normal resting and squeeze anal pressures.

RESULTS

Among 134 women, abnormal resting and/or squeeze pressures were identified in 113 and normal pressures were identified in 21. Women with normal sphincter pressures were younger (mean age 52.7 ± 10.8 years vs 59.0 ± 14.0 years, P = 0.036), more often had abnormal defecation indices (100% vs 83.2%, P = 0.043) and higher rectal defecation pressures (30.8 ± 18.8 mm Hg vs 50.8 ± 22.6 mm Hg, P < 0.001). There was an overall association between DD subtype and normal and abnormal sphincter pressure groups (P = 0.021). Dyssynergia subtypes I or III (odds ratio, 7.2; 95% confidence interval, 1.8-28.8) and age younger than 67 years (odds ratio, 8.5; 95% confidence interval, 1.5-48.6) were associated with greater odds of having normal sphincter pressures.

CONCLUSIONS

Female FI patients with normal anal sphincter pressures are younger, have higher rectal defecation pressures, and more often have type I or type III DD.

Clinical correlates of faecal incontinence in systemic sclerosis: identifying therapeutic avenues

Objectives

The aim was to establish the prevalence and severity of faecal incontinence (FI) in SSc, its association with other intestinal manifestations and potential predictors of FI, and its impact on quality of life.

Methods

A multicentre, cross-sectional study of 298 SSc subjects followed in the Canadian Scleroderma Research Group cohort was performed using validated questionnaires: Jorge-Wexner score (an FI severity scale), Bristol stool scale (a visual scale of stool consistency) and FI Quality-of-Life scale. Constipation was defined by the Rome III criteria. Associations between the Jorge-Wexner score and other clinical variables were determined using multivariate regression analyses.

Results

Eighty-one (27.2%) subjects had FI, which was mild in 37 (12.4%) and moderate to severe in 44 (14.8%). Most patients had well-formed stools, 111 (38.8%) reported constipation and 38 (13.4%) had been previously treated for small intestinal bacterial overgrowth (SIBO). Variables independently associated with FI were: loose vs well-formed stools [odds ratio (OR) = 7.01, 95% CI: 2.09, 23.51)], constipation (OR = 3.64, 95% CI: 1.61, 8.27, P = 0.002), history of SIBO (OR = 2.97, 95% CI: 1.06, 8.27) and urinary incontinence (OR = 2.45, 95% CI: 1.14, 5.27). Quality of life measured with the FI Quality-of-Life scale was inversely correlated with FI severity (correlation coefficients between -0.602 and -0.702, P < 0.001).

Conclusion

FI was common and often severe in SSc. Loose stools, SIBO, constipation and urinary incontinence were strongly associated with FI. Other than targeting anorectal dysfunction, concomitant treatment of clinical correlates could lead to improvement in FI and quality of life in SSc.

Systematic Review of Animal Models Used in Research of Origins and Treatments of Fecal Incontinence

BACKGROUND

Fecal incontinence is a common disorder, but its pathophysiology is not completely understood.

OBJECTIVE

The aim of this review is to present animal models that have a place in the study of fecal incontinence.

DATA SOURCES

A literature review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines performed in August 2016 revealed 50 articles of interest. Search terms included fecal/faecal incontinence and animal model or specific species.

STUDY SELECTION

Articles not describing an animal model, in vitro studies, veterinary literature, reviews, and non-English articles were excluded.

MAIN OUTCOME MEASURES

The articles described models in rats (n = 31), dogs (n = 8), rabbits (n = 7), and pigs (n = 4).

RESULTS

Different fecal incontinence etiologies were modeled, including anal sphincter lesions (33 articles) ranging from a single anal sphincter cut to destruction of 50% of the anal sphincter by sharp dissection, electrocautery, or diathermy. Neuropathic fecal incontinence (12 articles) was achieved by complete or incomplete pudendal, pelvic, or inferior rectal nerve damage. Mixed fecal incontinence (5 articles) was modeled either by the inflation of pelvic balloons or an array of several lesions including nervous and muscular damage. Anal fistulas (2 articles), anal sphincter resection (3 articles), and diabetic neuropathy (2 articles) were studied to a lesser extent.

LIMITATIONS

Bias may have arisen from the authors' own work on fecal incontinence and the absence of blinding to the origins of articles.

CONCLUSIONS

Validated animal models representing the main etiologies of fecal incontinence exist, but no animal model to date represents the whole pathophysiology of fecal incontinence. Therefore, the individual research questions still dictate the choice of model and species.

Pathophysiology and Therapeutic Options for Fecal Incontinence

Fecal incontinence (FI), defined as the involuntary loss of solid or liquid feces through the anus is a prevalent condition with significant effects on quality of life. FI can affect individuals of all ages and in many cases greatly impairs quality of life but, incontinent patients should not accept their debility as either inevitable or untreatable. The severity of incontinence can range from unintentional elimination of flatus to the complete evacuation of bowel contents. It is reported to affect up to 18% of the population, with a prevalence reaching as high as 50% in nursing home residents. However, FI is often underreported, thus obscuring its true prevalence in the general population. The options for treatment vary according to the degree and severity of the FI. Treatment can include dietary and lifestyle modification, certain medications, biofeedback therapy, bulking agent injections, sacral nerve stimulation as well as various types of surgery. In this article, we aim to provide a comprehensive review on the diagnosis and management of FI.

Can incontinence be cured? A systematic review of cure rates

BACKGROUND

Incontinence constitutes a major health problem affecting millions of people worldwide. The present study aims to assess cure rates from treating urinary (UI) or fecal incontinence (FI) and the number of people who may remain dependent on containment strategies.

METHODS

Medline, Embase, PsycINFO, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, and PEDro were searched from January 2005 to June 2015. Supplementary searches included conference abstracts and trials registers (2013-2015). Included studies had patients ≥ 18 years with UI or FI, reported treatment cure or success rates, had ≥ 50 patients treated with any intervention recognized in international guideline algorithms, a follow-up ≥ 3 months, and were published from 2005 onwards. Title and abstract screening, full paper screening, data extraction and risk-of-bias assessment were performed independently by two reviewers. Disagreements were resolved through discussion or referral to a third reviewer where necessary. A narrative summary of included studies is presented.

RESULTS

Most evidence was found for UI: Surgical interventions for stress UI showed a median cure rate of 82.3% (interquartile range (IQR), 72-89.5%); people with urgency UI were mostly treated using medications (median cure rate for antimuscarinics = 49%; IQR, 35.6-58%). Pelvic floor muscle training and bulking agents showed lower cure rates for UI. Sacral neuromodulation for FI had a median cure rate of 38.6% (IQR, 35.6-40.6%).

CONCLUSIONS

Many individuals were not cured and hence may continue to rely on containment. No studies were found assessing success of containment strategies. There was a lack of data in the disabled and in those with neurological diseases, in the elderly and those with cognitive impairment. Surgical interventions were effective for stress UI. Other interventions for UI and FI showed lower cure rates. Many individuals are likely to be reliant on containment strategies.

PROSPERO REGISTRATION

PROSPERO registration number: CRD42015023763 .

Fecal incontinence - Challenges and solutions

Fecal incontinence is not a diagnosis but a frequent and debilitating common final pathway symptom resulting from numerous different causes. Incontinence not only impacts the patient's self-esteem and quality of life but may result in significant secondary morbidity, disability, and cost. Treatment is difficult without any panacea and an individualized approach should be chosen that frequently combines different modalities. Several new technologies have been developed and their specific roles will have to be defined. The scope of this review is outline the evaluation and treatment of patients with fecal incontinence.

Constipation in older people: A consensus statement

BACKGROUND AND AIMS

Chronic constipation is a serious medical condition that affects 30%-40% of people over 60 years old. Although not normally life threatening, constipation reduces quality of life by the same extent as diabetes and osteoarthritis. There are currently no Europe-wide guidelines for treating constipation in older people, although there is some country-level guidance for the general population. We have evaluated the existing guidance and best clinical practice to improve the care of older people with constipation.

METHOD

European healthcare professionals working in gastroenterology, geriatrics, nursing and pharmacology discussed the treatment of constipation in older people and reviewed existing guidance on the treatment of constipation in the general population. This manuscript represents the consensus of all authors.

DISCUSSION

Most general guidance for constipation treatment recommends increased dietary fibre, fluid intake and exercise; however, this is not always possible in older patients. Although a common first-line treatment, bulk-forming laxatives are unsuitable for older people because of an associated need to increase fluid intake, osmotic laxatives are likely to be the most suitable laxative type for older patients. Treatment is often hampered by reluctance to talk about bowel problems so healthcare providers should proactively identify older constipated patients who are self-medicating or not receiving treatment.

CONCLUSIONS

With certain modifications, general treatment guidelines can be applied to older people with constipation, although specific guidelines are still required for this age group. Awareness of constipation, its complications and treatment options need to be increased among healthcare providers, patients and carers.

Fecal Incontinence and Pelvic Floor Dysfunction in Women: A Review

Pelvic floor dysfunction and fecal incontinence is a common and debilitating condition in women, particularly as women age, and often goes under-reported to health care providers. It is important for providers to ask patients about possible symptoms. An algorithm for evaluation and treatment is presented. Current and future therapies are described and discussed.

Identifying factors associated with clinical success in patients treated with NASHA(®)/Dx injection for fecal incontinence

Purpose

Injection with the bulking agent consisting of non-animal stabilized hyaluronic acid/dextranomer (NASHA^®/Dx) is well tolerated and efficacious for the treatment of fecal incontinence (FI); however, the patient population that may derive maximum benefit has not been established. This post hoc responder analysis assessed demographic and baseline characteristics predictive of responsiveness to NASHA/Dx treatment.

Methods

Adults with a Cleveland Clinic Florida fecal incontinence score (CCFIS) ≥10 were randomized to receive NASHA/Dx or sham treatment. The primary end point was response to treatment (ie, decrease from baseline of ≥50% in number of FI episodes) at 6 months; a prespecified secondary end point was change in fecal incontinence quality of life (FIQL) score at 6 months. Post hoc subgroup analyses were performed for baseline and demographic characteristics and prior FI treatments.

Results

Overall, response to treatment was significantly greater with NASHA/Dx versus sham injection (52.7% vs 32.1%; P=0.0089). All subgroups analyzed demonstrated evidence of improvement, favoring NASHA/Dx versus sham treatment for both response to treatment and change in the FIQL coping/behavior subscale score. For the primary end point, a significantly greater percentage of patients with CCFIS ≤15, FI symptoms ≤5 years’ duration, or obstetric causes of FI responded to NASHA/Dx treatment versus patients receiving sham treatment (51.1% vs 28.3%, P=0.0169; 55.4% vs 25.7%, P=0.0026; and 53.6% vs 23.1%, P=0.0191, respectively). The mean change in the FIQL coping/behavior score significantly favored NASHA/Dx versus sham treatment for patients with CCFIS ≤15 (P=0.0371), FI symptoms ≤5 years’ duration (P=0.0289), or obstetric causes of FI (P=0.0384). Patients without a history of specific FI treatments (eg, antidiarrheal medications, biofeedback, surgery) were more likely to respond to NASHA/Dx versus sham treatment for both end points.

Conclusion

Although all subgroups analyzed showed evidence of quantitative and qualitative benefit from NASHA/Dx therapy, patients with characteristics indicative of mild-to-moderate FI may exhibit the greatest benefit.

Functional Anorectal Disorders

This report defines criteria and reviews the epidemiology, pathophysiology, and management of common anorectal disorders: fecal incontinence (FI), functional anorectal pain and functional defecation disorders. FI is defined as the recurrent uncontrolled passage of fecal material for at least 3 months. The clinical features of FI are useful for guiding diagnostic testing and therapy. Anorectal manometry and imaging are useful for evaluating anal and pelvic floor structure and function. Education, antidiarrheals and biofeedback therapy are the mainstay of management; surgery may be useful in refractory cases. Functional anorectal pain syndromes are defined by clinical features and categorized into three subtypes. In proctalgia fugax, the pain is typically fleeting and lasts for seconds to minutes. In levator ani syndrome (LAS) and unspecified anorectal pain the pain lasts more than 30 minutes, but in LAS there is puborectalis tenderness. Functional defecation disorders are defined by >2 symptoms of chronic constipation or irritable bowel syndrome with constipation, and with >2 features of impaired evacuation i.e., abnormal evacuation pattern on manometry, abnormal balloon expulsion test or impaired rectal evacuation by imaging. It includes two subtypes; dyssynergic defecation and inadequate defecatory propulsion. Pelvic floor biofeedback therapy is effective for treating LAS and defecatory disorders.

Functional Anorectal Disorders

This report defines criteria and reviews the epidemiology, pathophysiology, and management of common anorectal disorders: fecal incontinence (FI), functional anorectal pain and functional defecation disorders. FI is defined as the recurrent uncontrolled passage of fecal material for at least 3 months. The clinical features of FI are useful for guiding diagnostic testing and therapy. Anorectal manometry and imaging are useful for evaluating anal and pelvic floor structure and function. Education, antidiarrheals and biofeedback therapy are the mainstay of management; surgery may be useful in refractory cases. Functional anorectal pain syndromes are defined by clinical features and categorized into three subtypes. In proctalgia fugax, the pain is typically fleeting and lasts for seconds to minutes. In levator ani syndrome (LAS) and unspecified anorectal pain the pain lasts more than 30 minutes, but in LAS there is puborectalis tenderness. Functional defecation disorders are defined by >2 symptoms of chronic constipation or irritable bowel syndrome with constipation, and with >2 features of impaired evacuation i.e., abnormal evacuation pattern on manometry, abnormal balloon expulsion test or impaired rectal evacuation by imaging. It includes two subtypes; dyssynergic defecation and inadequate defecatory propulsion. Pelvic floor biofeedback therapy is effective for treating LAS and defecatory disorders.

Artificial Muscle Devices: Innovations and Prospects for Fecal Incontinence Treatment

Fecal incontinence describes the involuntary loss of bowel content, which is responsible for stigmatization and social exclusion. It affects about 45% of retirement home residents and overall more than 12% of the adult population. Severe fecal incontinence can be treated by the implantation of an artificial sphincter. Currently available implants, however, are not part of everyday surgery due to long-term re-operation rates of 95% and definitive explantation rates of 40%. Such figures suggest that the implants fail to reproduce the capabilities of the natural sphincter. This article reviews the artificial sphincters on the market and under development, presents their physical principles of operation and critically analyzes their performance. We highlight the geometrical and mechanical parameters crucial for the design of an artificial fecal sphincter and propose more advanced mechanisms of action for a biomimetic device with sensory feedback. Dielectric electro-active polymer actuators are especially attractive because of their versatility, response time, reaction forces, and energy consumption. The availability of such technology will enable fast pressure adaption comparable to the natural feedback mechanism, so that tissue atrophy and erosion can be avoided while maintaining continence during daily activities.

Age, Gender and Women's Health and the Patient

Patients with functional gastrointestinal disorders (FGIDs) often experience distress, reduced quality of life, a perceived lack of validation, and an unsatisfactory experience with health care providers. A health care provider can provide the patient with a framework in which to understand and legitimize their symptoms, remove self-doubt or blame, and identify factors that contribute to symptoms that the patient can influence or control. This framework is implemented with the consideration of important factors that impact FGIDs, such as gender, age, society, and the patient's perspective. Although the majority of FGIDs, including globus, rumination syndrome, IBS, bloating, constipation, functional abdominal pain, sphincter of Oddi dyskinesia, pelvic floor dysfunction, and extra-intestinal manifestations, are more prevalent in women than men, functional chest pain, dyspepsia, vomiting, and anorectal pain do not appear to vary by gender. Studies suggest sex differences in somatic but not visceral pain perception, motility, and central processing of visceral pain; although further research is required in autonomic nervous system dysfunction, genetics and immunologic/microbiome. Gender differences in response to psychological treatments, antidepressants, fiber, probiotics, and anticholinergics have not been adequately studied. However, a greater clinical response to 5-HT3 antagonists but not 5-HT4 agonists has been reported in women compared with men.

Fecal impaction: a systematic review of its medical complications

Background

Fecal impaction (FI) is a common problem in the elderly and other at-risk groups, such as patients with a neuro-psychiatric disease. It has been associated with medical problems and high morbi-mortality. A systematic review of this topic might be useful to improve the knowledge in this area and helpful to make an appropriate and early diagnosis.

Methods

A PubMed systematic search was performed using relevant keywords. Case reports published in English, Spanish or French till June 2014 were included if they had a diagnosis of FI and a medical complication secondary to it. Each case was classified based on its principal complication. The main objective is to create a classification of FI complications based on published clinical cases.

Results

188 articles met inclusion criteria, comprising 280 clinical cases. Out of the total, 43,5 % were over 65 years old, 49 % suffered from chronic constipation, 29 % had an underlying neuropsychiatric disease and 15 % were hospitalised or institutionalised. A total of 346 medical complications secondary to FI were collected. They were divided according to gastrointestinal tract involvement and then classified based on their anatomical and pathophysiological mechanism into three groups: Complications secondary to fecaloma effect on the intestinal wall (73.4 %), on the intestinal lumen (14 %) and on adjacent structures (12.6 %).

Conclusions

FI causes complications that might be fatal. The elderly, underlying neuropsychiatric disease and hospitalised or institutionalised patients integrate the high-risk group in which FI must be suspected. The first FI complications classification is presented to improve the knowledge about this entity.

Management of patients with faecal incontinence

Faecal incontinence, defined as the involuntary loss of solid or liquid stool, is a common problem affecting 0.8-8.3% of the adult population. Individuals suffering from faecal incontinence often live a restricted life with reduced quality of life. The present paper is a clinically oriented review of the pathophysiology, evaluation and treatment of faecal incontinence. First-line therapy should be conservative and usually include dietary adjustments, fibre supplement, constipating agents or mini enemas. Biofeedback therapy to improve external anal sphincter function can be offered but the evidence for long-term effect is poor. There is good evidence that colonic irrigation can reduce symptoms and improve quality of life, especially in patients with neurogenic faecal incontinence. Surgical interventions should only be considered if conservative measures fail. Sacral nerve stimulation is a minimally invasive procedure with high rate of success. Advanced surgical procedures should be restricted to highly selected patients and only performed at specialist centres. A stoma should be considered if other treatment modalities fail.

Analysis of Racial and Ethnic Disparities as Possible Risk Factors for Development of Incontinence by Nursing Home Residents

Incontinence is a common health problem among nursing home (NH) residents. Differences between black and white NH residents in incontinence prevalence have been reported. Although reducing health disparities is a principal objective of the national health care agenda, little is known about disparities in incidence of new incontinence in NHs. The purpose of this study was to assess whether there were racial/ethnic disparities in the time to development of incontinence in adults over age 65 who had been continent on NH admission. If no racial or ethnic disparities in time to incontinence were found, other predictors of time to incontinence would be explored. Three national databases were sources of data on 42,693 adults over 65 admitted to 446 for-profit NHs in a national chain. Multi-level predictors of time to any type of incontinence were analyzed, using Cox proportional hazards regression for white Non-Hispanic NH admissions and the Peters-Belson method for minority NH admissions: American Indians/Alaskan Natives, Asians/Pacific Islanders, Black non-Hispanics, and Hispanics. No racial/ethnic disparities in time to incontinence were found. Approximately 30% of all racial/ethnic groups had developed incontinence by 6 months. Those who developed incontinence sooner were older and had greater deficits in activities of daily living (ADL) and cognition. Results were consistent with past evidence and suggest that interventions to maintain continence from the time of admission should be applied across racial/ethnic groups.

Sacral nerve stimulation for faecal incontinence and constipation in adults

BACKGROUND

Faecal incontinence (FI) and constipation are both socially-embarrassing and physically-disabling conditions that impair quality of life. For both, surgery may be required in a minority of people when more conservative measures fail. However, the invasiveness and irreversible nature of direct surgery on bowel and sphincter muscles, poor long-term outcomes and well-established compIications makes such procedures unappealing for these benign conditions. A less-invasive surgical option to treat faecal incontinence and constipation is direct, low-voltage stimulation of the sacral nerve roots, termed sacral nerve stimulation (SNS). SNS has become the first line surgical treatment for FI in people failing conservative therapies. Its value in the treatment of constipation is less clear.

OBJECTIVES

To assess the effects of sacral nerve stimulation using implanted electrodes for the treatment of faecal incontinence and constipation in adults.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, ClinicalTrials.gov, the World Health Organization (WHO) ICTRP and handsearched journals and conference proceedings (searched 5 February 2015), EMBASE (1 January 1947 to 2015 Week 5), and the reference lists of retrieved relevant articles.

SELECTION CRITERIA

All randomised or quasi-randomised trials assessing the effects of SNS for faecal incontinence or constipation in adults.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the search results, assessed the methodological quality of the included trials, and undertook data extraction.

MAIN RESULTS

Six crossover trials and two parallel group trials were included.Six trials assessed the effects of SNS for FI. In the parallel group trial conducted by Tjandra, 53 participants with severe FI in the SNS group experienced fewer episodes of faecal incontinence compared to the control group who received optimal medical therapy (mean difference (MD) -5.20, 95% confidence interval (CI) -9.15 to -1.25 at 3 months; MD -6.30, 95% CI -10.34 to -2.26 at 12 months). Adverse events were reported in a proportion of participants: pain at implant site (6%), seroma (2%) and excessive tingling in the vaginal region (9%).In the parallel group trial carried out by Thin, 15 participants with FI in the SNS group experienced fewer episodes of FI compared with the percutaneous tibial nerve stimulation (PTNS) group (MD -3.00, 95% CI -6.61 to 0.61 at 3 months; MD -3.20, 95% CI -7.14 to 0.74 at 12 months). Adverse events were reported in three participants: mild ipsilateral leg pain during temporary testing (n = 1); and stimulator-site pain following insertion of neurostimulator (n = 2).In the crossover trial by Leroi 7 of 34 recruited participants were excluded from the crossover due mainly to complications or immediate device failure. Twenty-four of the remaining 27 participants while still blinded chose the period of stimulation they had preferred. Outcomes were reported separately for 19 participants who preferred the 'on' and five who preferred the 'off' period. For the group of 19, the median (range) episodes of faecal incontinence per week fell from 1.7 (0 to 9) during the 'off' period to 0.7 (0 to 5) during the 'on' period; for the group of five, however, the median (range) rose from 1.7 (0 to 11) during the 'off' period compared with 3.7 (0 to 11) during the 'on' period. Four of 27 participants experienced an adverse event resulting in removal of the stimulator.In the crossover trial by Sørensen and colleagues, participants did not experience any FI episodes in either the one-week 'on' or 'off' periods.In the crossover trial by Vaizey, participants reported an average of six, and one, episodes of faecal incontinence per week during the 'off' and 'on' periods respectively in two participants with FI. Neither study reported adverse events.In the crossover trial by Kahlke, 14 participants with FI experienced significantly lower episodes of FI per week during the stimulator 'on' (1 (SD, 1.7)) compared with the 'off' period (8.4 (SD, 8.7)). Adverse events reported include: haematoma formation (n = 3); misplacement of tined lead (1); and pain at stimulator site (n = 1).Two trials assessed SNS for constipation. In the Kenefick trial, the two participants experienced an average of two bowel movements per week during the 'off' crossover period, compared with five during the 'on' period. Abdominal pain and bloating occurred 79% of the time during the 'off' period compared with 33% during the 'on' period. No adverse events occurred. In contrast, in the trial by Dinning with 59 participants, SNS did not improve frequency of bowel movements and 73 adverse events were reported, which included pain at site of the implanted pulse generator (32), wound infection (12), and urological (17) events.

AUTHORS' CONCLUSIONS

The limited evidence from the included trials suggests that SNS can improve continence in a proportion of patients with faecal incontinence. However, SNS did not improve symptoms in patients with constipation. In addition, adverse events occurred in some patients where these were reported. Rigorous high quality randomised trials are needed to allow the effects of SNS for these conditions to be assessed with more certainty.

Reducing and managing faecal incontinence in people with advanced dementia who are resident in care homes: protocol for a realist synthesis

INTRODUCTION

Faecal incontinence (FI) is the involuntary loss of liquid or solid stool that is a social or hygienic problem. The prevalence of FI in residents of care homes is high, but it is not an inevitable consequence of old age or dementia. There is good evidence on risk factors, but few studies provide evidence about effective interventions. There is a need to understand how, why, and in what circumstances particular programmes to reduce and manage FI are effective (or not) for people with dementia. The purpose of this review is to identify which (elements of the) interventions could potentially be effective, and examine the barriers and facilitators to the acceptability, uptake and implementation of interventions designed to address FI in people with dementia who are resident in care homes.

METHODS AND ANALYSIS

A realist synthesis approach to review the evidence will be used which will include studies on continence, person-centred care, implementation research in care homes, workforce and research on care home culture. An iterative four-stage approach is planned. Phase 1: development of an initial programme theory or theories that will be 'tested' through a first scoping of the literature and consultation with five stakeholder groups (care home providers, user representatives, academics and practice educators, clinicians with a special interest in FI and continence specialists). Phase 2: a systematic search and analysis of published and unpublished evidence to test and develop the programme theories identified in phase 1. Phase 3: validation of programme theory/ies with a purposive sample of participants from phase 1.

ETHICS AND DISSEMINATION

The overall protocol does not require ethical review. The University research ethics committee will review interviews conducted as part of phase 1 and 3. The final fourth phase will synthesise and develop recommendations for practice and develop testable hypotheses for further research.

Prevalence of functional bowel disorders and faecal incontinence: an Australian primary care survey

AIM

Interest in functional bowel disorders (FBDs) and faecal incontinence (FI) has increased amongst coloproctologists. The study aimed to assess the prevalence of FBDs and FI (including its severity) among Australian primary healthcare seekers using objective criteria.

METHOD

A cross-sectional survey was conducted in a primary care setting in Sydney, Australia. A self-administered questionnaire was used to collect demographic information and diagnose FBDs (irritable bowel syndrome, constipation, functional bloating and functional diarrhoea) based on Rome III criteria. The severity of FI was determined using the Vaizey incontinence score. Associations with medical/surgical history and healthcare utilization were assessed.

RESULTS

Of 596 subjects approached, 396 (66.4%) agreed to participate. Overall, 33% had FBD and/or FI. Irritable bowel syndrome was present in 11.1% and these participants were more likely to report anxiety/depression (P < 0.01) and to have had a previous colonoscopy (P < 0.001) or cholecystectomy (P = 0.02). Functional constipation was present in 8.1%, and functional bloating and functional diarrhoea were diagnosed in 6.1%, and 1.5%, respectively. FI was present in 12.1% with the majority (52%) reporting moderate/severe incontinence (Vaizey score > 8). Participants with FI were more likely to have irritable bowel syndrome, urinary incontinence and previous anal surgery (P < 0.01).

CONCLUSION

FBDs and FI are prevalent conditions amongst primary healthcare seekers and the needs of those affected appear to be complex given their coexisting symptoms and conditions. Currently, the majority do not reach colorectal services, although increased awareness by primary care providers could lead to sufferers being referred for specialist management.

Epidemiology, pathophysiology, and classification of fecal incontinence: state of the science summary for the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) workshop

In August 2013, the National Institutes of Health sponsored a conference to address major gaps in our understanding of the epidemiology, pathophysiology, and management of fecal incontinence (FI) and to identify topics for future clinical research. This article is the first of a two-part summary of those proceedings. FI is a common symptom, with a prevalence that ranges from 7 to 15% in community-dwelling men and women, but it is often underreported, as providers seldom screen for FI and patients do not volunteer the symptom, even though the symptoms can have a devastating impact on the quality of life. Rough estimates suggest that FI is associated with a substantial economic burden, particularly in patients who require surgical therapy. Bowel disturbances, particularly diarrhea, the symptom of rectal urgency, and burden of chronic illness are the strongest independent risk factors for FI in the community. Smoking, obesity, and inappropriate cholecystectomy are emerging, potentially modifiable risk factors. Other risk factors for FI include advanced age, female gender, disease burden (comorbidity count, diabetes), anal sphincter trauma (obstetrical injury, prior surgery), and decreased physical activity. Neurological disorders, inflammatory bowel disease, and pelvic floor anatomical disturbances (rectal prolapse) are also associated with FI. The pathophysiological mechanisms responsible for FI include diarrhea, anal and pelvic floor weakness, reduced rectal compliance, and reduced or increased rectal sensation; many patients have multifaceted anorectal dysfunctions. The type (urge, passive or combined), etiology (anorectal disturbance, bowel symptoms, or both), and severity of FI provide the basis for classifying FI; these domains can be integrated to comprehensively characterize the symptom. Several validated scales for classifying symptom severity and its impact on the quality of life are available. Symptom severity scales should incorporate the frequency, volume, consistency, and nature (urge or passive) of stool leakage. Despite the basic understanding of FI, there are still major knowledge gaps in disease epidemiology and pathogenesis, necessitating future clinical research in FI.

Current and emerging treatment options for fecal incontinence

Fecal incontinence (FI) is a multifactorial disorder that imposes considerable social and economic burdens. The aim of this article is to provide an overview of current and emerging treatment options for FI. A MEDLINE search was conducted for English-language articles related to FI prevalence, etiology, diagnosis, and treatment published from January 1, 1990 through June 1, 2013. The search was extended to unpublished trials on ClinicalTrials.gov and relevant publications cited in included articles. Conservative approaches, including dietary modifications, medications, muscle-strengthening exercises, and biofeedback, have been shown to provide short-term benefits. Transcutaneous electrical stimulation was considered ineffective in a randomized clinical trial. Unlike initial studies, sacral nerve stimulation has shown reasonable short-term effectiveness and some complications. Dynamic graciloplasty and artificial sphincter and bowel devices lack randomized controlled trials and have shown inconsistent results and high rates of explantation. Of injectable bulking agents, dextranomer microspheres in non-animal stabilized hyaluronic acid (NASHA Dx) has shown significant improvement in incontinence scores and frequency of incontinence episodes, with generally mild adverse effects. For the treatment of FI, conservative measures and biofeedback therapy are modestly effective. When conservative therapies are ineffective, invasive procedures, including sacral nerve stimulation, may be considered, but they are associated with complications and lack randomized, controlled trials. Bulking agents may be an appropriate alternative therapy to consider before more aggressive therapies in patients who fail conservative therapies.

ACG clinical guideline: management of benign anorectal disorders

These guidelines summarize the definitions, diagnostic criteria, differential diagnoses, and treatments of a group of benign disorders of anorectal function and/or structure. Disorders of function include defecation disorders, fecal incontinence, and proctalgia syndromes, whereas disorders of structure include anal fissure and hemorrhoids. Each section reviews the definitions, epidemiology and/or pathophysiology, diagnostic assessment, and treatment recommendations of each entity. These recommendations reflect a comprehensive search of all relevant topics of pertinent English language articles in PubMed, Ovid Medline, and the National Library of Medicine from 1966 to 2013 using appropriate terms for each subject. Recommendations for anal fissure and hemorrhoids lean heavily on adaptation from the American Society of Colon and Rectal Surgeons Practice Parameters from the most recent published guidelines in 2010 and 2011 and supplemented with subsequent publications through 2013. We used systematic reviews and meta-analyses when available, and this was supplemented by review of published clinical trials.

Emerging surgical therapies for faecal incontinence

Faecal incontinence is a common condition and is associated with considerable morbidity and economic cost. The majority of patients are managed with conservative interventions. However, for those patients with severe or refractory incontinence, surgical treatment might be required. Over the past 20 years, numerous developments have been made in the surgical therapies available to treat such patients. These surgical therapies can be classified as techniques of neuromodulation, neosphincter creation (muscle or artificial) and injection therapy. Techniques of neuromodulation, particularly sacral nerve stimulation, have transformed the management of these patients with a minimally invasive procedure that offers good results and low morbidity. By contrast, neosphincter procedures are characterized by being more invasive and associated with considerable morbidity, although some patients will experience substantial improvements in their continence. Injection of bulking agents into the anal canal can improve symptoms and quality of life in patients with mild-to-moderate incontinence, and the use of autologous myoblasts might be a future therapy. Further research and development is required not only in terms of the devices and procedures, but also to identify which patients are likely to benefit most from such interventions.