Measuring fecal incontinence

Long-term Outcomes of Sacral Nerve Stimulation on the Treatment of Fecal Incontinence: A Systematic Review

INTRODUCTION

Sacral nerve stimulation (SNS) has now been used as a treatment for fecal incontinence (FI) for >20 years. The aim of this systematic review was to determine the long-term efficacy of SNS on the treatment of FI.

MATERIALS AND METHODS

A comprehensive search of the MEDLINE, Embase, and Cochrane Central data bases was performed to find publications, excluding case reports, reporting outcomes of SNS treatment for FI in adults with ≥36 months of follow-up. Bias was assessed using the Risk of Bias in Non-randomized Studies-of Interventions tool. Data were summarized per reported FI-related outcomes for symptom severity and quality of life.

RESULTS

In total, 3326 publications were identified, and 36 studies containing 3770 subjects were included. All studies had a serious risk of bias. Success was variably defined by each publication and ranged from 59.4% to 87.5% for per-protocol analyses and 20.9% to 87.5% for intention-to-treat analyses. All studies reporting bowel diary data, St Mark's scores, and Cleveland Clinic Incontinence Scores indicated significant improvement with SNS treatment in the long term. Studies that evaluated quality-of-life outcomes also all showed improvements in quality of life as measured by the Fecal Incontinence Quality of Life Scale. The aggregate revision rate was 35.2%, and the explantation rate was 19.7%.

CONCLUSIONS

Improvements in objective and subjective outcomes at ≥36 months support using SNS for the long-term treatment of FI. Interpretation of these data is limited by a lack of comparative trials and heterogeneity of the included studies.

Diagnostic tools for fecal incontinence: Scoring systems are the crucial first step

The main aim of this editorial is to comment on the recent article published by Garg et al in the World Journal of Gastroenterology 2023; 29: 4593-4603. This original research presents a new scoring system for fecal incontinence. Fecal incontinence is a chronic disease with a severe impact on the quality of life of the patients. Substantial social stigmatization often leads to significant underreporting of the condition even during visits to a specialist and could lead to further mismanagement or non-existent management of the disease. An important fact is that patients are often unable to describe their condition when not asked precisely defined questions. This problem is partially resolved by scoring questionnaires. Several scoring systems are commonly used; however, each of them has their shortcomings. For example, the absence of different kinds of leakage besides flatus and stool could further lead to underscoring the incontinence severity. Therefore, there has long been a call for a more precise scoring system. The correct identification of the presence and severity of fecal incontinence is paramount for further diagnostic approach and for choosing the appropriate therapy option. This editorial describes fecal incontinence, its effect on quality of life in general and further evaluates the diagnostic approach with a particular focus on symptom scoring systems and their implications for clinical practice.

The Long-term Outcomes of Sacral Neuromodulation for Fecal Incontinence: A Single-Center Experience

BACKGROUND

Sacral neuromodulation is an effective treatment for fecal incontinence.

OBJECTIVE

To assess the long-term outcomes of sacral neuromodulation and establish the outcomes of patients with inactive devices.

DESIGN

This is an observational study of patients treated for >5 years. A positive outcome was defined as a more than 50% reduction in fecal incontinence episodes or improvement in a symptom severity score. Data were reviewed from a prospectively managed database.

SETTINGS

This study was conducted at a single tertiary referral center.

PATIENTS

Data from 74 patients (72 women) were available at long-term follow-up.

MAIN OUTCOME MEASURES

Bowel diary, St. Mark's incontinence score, and Manchester Health Questionnaire data were prospectively recorded at baseline, after percutaneous nerve evaluation, and at last follow-up.

RESULTS

Patients were analyzed in cohorts based on time since sacral neuromodulation implantation: group 1: 5 to 10 years (n = 20), group 2: >10 years (n = 35), and group 3: inactive sacral neuromodulation devices (n = 19). Median St. Mark's incontinence score and Manchester Health Questionnaire improved from baseline to last follow-up in group 1 ( p ≤ 0.05) and group 2 ( p ≤ 0.05), but in group 3, results returned to baseline levels at the last follow-up. Similarly, weekly fecal incontinence episodes improved in both active device groups at the last follow-up. However, in group 3, incontinence episodes were no different from baseline ( p = 0.722). Despite active devices, fecal urgency episodes increased at the last follow-up after >10 years since percutaneous nerve evaluation ( p ≤ 0.05). Complete continence was reported by 44% of patients, and at least a 50% improvement was seen in 77% of patients with active devices.

LIMITATIONS

This study is retrospective with some gaps in the available data at the last follow-up.

CONCLUSIONS

Sacral neuromodulation is an effective treatment for fecal incontinence in the long term, but all outcomes are adversely affected by device inactivity. Therefore, ongoing stimulation is required for continued benefit. See Video Abstract.

RESULTADOS A LARGO PLAZO DE LA NEUROMODULACIN SACRA PARA LA INCONTINENCIA FECAL EXPERIENCIA DE UN SOLO CENTRO

ANTECEDENTES:La neuromodulación sacra es un tratamiento eficaz para la incontinencia fecal.OBJETIVO:Este estudio tuvo como objetivo evaluar los resultados a largo plazo de la neuromodulación sacra y establecer los resultados de los pacientes con dispositivos inactivos.DISEÑO:Este es un estudio observacional de pacientes tratados durante más de 5 años. Un resultado positivo se definió como una reducción >50 % en los episodios de incontinencia fecal o una mejoría en la puntuación de gravedad de los síntomas. Los datos se revisaron a partir de una base de datos administrada prospectivamente.ENTERNO CLINICO:Este estudio se realizó en un solo centro de referencia terciario.PACIENTES:Los datos de 74 pacientes (72 mujeres) estaban disponibles en el seguimiento a largo plazo.PRINCIPALES MEDIDAS DE RESULTADO:Diario intestinal, puntuación de incontinencia de St. Mark y datos del Cuestionario de salud de Manchester se registraron prospectivamente al inicio, después de la evaluación de nervio periférico y en el último seguimiento.RESULTADOS:Los pacientes se analizaron en cohortes según el tiempo transcurrido desde la implantación de la neuromodulación sacra: Grupo 1: 5-10 años (n = 20), Grupo 2: >10 años (n = 35) y Grupo 3: dispositivos SNM inactivos (n = 19). La mediana de la puntuación de incontinencia de St. Mark y Questionnaire Cuestionario de salud de Manchester mejoraron desde el inicio hasta el último seguimiento en el Grupo 1 (p = < 0,05) y el Grupo 2 (p = < 0,05), pero en el Grupo 3 los resultados volvieron a los niveles iniciales en el último seguimiento. arriba. De manera similar, los episodios semanales de incontinencia fecal mejoraron en ambos grupos de dispositivos activos en el último seguimiento. Sin embargo, en el Grupo 3 los episodios de incontinencia no fueron diferentes de los basales (p = 0,722). A pesar de los dispositivos activos, los episodios de urgencia fecal aumentaron en el último seguimiento después de más de 10 años desde la evaluación del nervio periférico (p = < 0,05). Continencia completa se reportó en el 44 % de los pacientes, y al menos una mejora del 50 % en el 77 % con dispositivos activos.LIMITACIONES:Este estudio es retrospectivo con algunas vacíos en los datos disponibles en el último seguimiento.CONCLUSIONES:La neuromodulación sacra es un tratamiento eficaz para la incontinencia fecal a largo plazo, pero todos los resultados se ven afectados negativamente por la inactividad del dispositivo. Por lo tanto, se requiere estimulación continua para un beneficio continuo. (Traducción- Dr. Francisco M. Abarca-Rendon ).

Usability evaluation of the Computer-Based Health Evaluation System (CHES) eDiary for patients with faecal incontinence: a pilot study

Background

Faecal incontinence (FI) is prevalent in 15–20% of elderly individuals and is frequently monitored in clinical trials and practice. Bowel diaries are the most common way to document FI, but, in clinical practice, are mainly used as paper-based versions. Electronic diaries (eDiaries) offer many potential benefits over paper-based diaries. The aim of this study was to develop and test an eDiary to document FI.

Methods

We migrated a paper FI diary to an eDiary app based on the Computer-based Health Evaluation System (CHES). To assess usability, we conducted functionality and usability tests at two time points in a sample of patients with FI. In the first assessment, the eDiary functionalities were tested, patients completed the System Usability Scale (SUS, range 0–100) and compared the paper diary with the eDiary. We set a threshold for minimum acceptable average usability at 70 points. Patients were then instructed to use the eDiary for 2 days at home and contacted to report on their usage and completed the SUS a second time.

Results

We recruited a sample of N = 14 patients to use the eDiary. All patients were able to use all functionalities of the eDiary and only a few patients with lower technological literacy or access to devices (n = 3) needed initial assistance. The mean usability rating given at the first time point was high with 88 points (SD 18, 95% CI 78.2–96.8) and most patients (n = 10) reported they would prefer the eDiary over the paper-based version. Nine patients (n = 9) participated in the follow-up assessment and the mean SUS rating at the second time point was 97 points (SD 7, 95% CI 92.8–100).

Conclusion

The eDiary showed excellent usability scores for the assessment of FI at both assessments. Generally, patients preferred the eDiary over the paper-based version. We recommend the eDiary for usage with patients who own and use a smartphone and discuss potential solutions for patients with lower technological literacy or access.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-01818-5.

A European snapshot of psychosocial characteristics and patients' perspectives of faecal incontinence-do they correlate with current scoring systems?

PURPOSE

To compare the current clinical scoring systems used to quantify the severity of symptoms of faecal incontinence (FI) to patients' subjective scoring of parameters of psychosocial well-being.

METHODS

Patients referred to six European centres for investigation or treatment of symptoms of FI between June 2017 and September 2019 completed a questionnaire that captured patient demographics, incontinence symptoms using St. Mark's Incontinence score (SMIS) and ICIQ-B, psychological well-being (HADS, Hospital Anxiety and Depression Scale), and social interaction (a three-item loneliness scale).

RESULTS

Three hundred eighteen patients completed questionnaires (62 men, mean age 58.7). Sixty percent of the respondents were aged under 65. Median SMIS was 15 (11-18), ICIQ-B bowel pattern was 8 (6-11) and bowel control was 17 (13-22), similar across all demographic groups; however, younger patients were more likely to experience symptoms of depression and anxiety (HADS score > 10, 65.2% of patients age < 65 vs 54.9% of those ages > = 65, p = 0.03) with lower quality of life (ICIQ-B QoL, median score 19 (14-23)) vs age > = 65 (16 (11-21) (p < 0.005)). On loneliness score 25.5% reported often feeling isolated from others. One of the most significant concerns by patients was the fear and embarrassment related to unpredictable episodes of incontinence.

CONCLUSION

The SMIS remains a useful tool for quantifying incontinence symptoms but may underestimate the psychosocial morbidity associated with unpredictable episodes of incontinence. Interventions aimed at decreasing anxiety and to address feelings of disgust may be helpful for a significant number of patients requiring treatment for FI.

Total mesorectal excision and sphincter preservation — the early steps of rectal cancer surgery

The treatment of rectal cancer has evolved significantly over the last 100 years. Standardization of total mesorectal excision and the development of techniques for sphincter preservation have resulted in significant improvements in the management of this disease. Still, local disease control and functional outcomes of sphincter preserving procedures remain a relevant issue. In this historical paper, the oncological and functional outcomes of patients with rectal cancer treated between 1960 and 1971 by a pioneer woman surgeon using a sphincter preserving approach and a technique resembling total mesorectal excision performed at that time are reported. The results reflect one of the earliest steps of partial intersphincteric resection and total mesorectal excision with good oncological outcomes (2% local recurrence) and acceptable functional outcomes in a highly selected group of patients.

Metrics Used to Quantify Fecal Incontinence and Constipation

While fecal incontinence and constipation can be measured through physiological testing, the subjective experience of severity and impact on health-related quality of life lead to both being most effectively captured through patient-reported measures. Patient-reported measures of severity and impact help to determine baseline symptoms, guide clinical decision making, and compare various treatments. Here, we take pause to review the psychometric qualities that make effective instruments, and discuss some of the most commonly used instruments along with the reasons behind their use. In addition, we highlight the benefits of a standardized instrument designed to evaluate the major symptoms of patients presenting with pelvic floor disorders (including fecal incontinence and constipation). Ultimately, we aim to provide guidance in choosing appropriate instruments for clinical and research use.

The relationships between the results of contemporary tests of anorectal structure and sensorimotor function and the severity of fecal incontinence

BACKGROUND

Diagnostic investigations for fecal incontinence (FI) assess the structure and sensorimotor function of the anorectum. Investigations include anorectal manometry, anorectal sensory testing, pudendal nerve terminal motor latencies (PNTML), and endoanal sonography. The severity of FI and results of investigations are often discordant and the rate of symptom resolution following treatment remains <40%. High-resolution anorectal manometry (HRAM) and three-dimensional endoanal ultrasound (3D-US) have been introduced during the last decade. This study aims to assess the strength of relationships between contemporary investigation results and FI severity.

METHODS

Adults presenting for investigation of FI were assessed using the St Mark's FI severity score (SMIS), HRAM, anorectal sensory testing, PNTML, and 3D-US.

KEY RESULTS

246 patients were included. There were significant relationships between the SMIS and HRAM (resting pressure r_s = -0.23, 95% CI = (-0.34, -0.11), P < .001; squeeze pressure (r_s  = -0.26, 95% CI = (-0.37, -0.14), P < .001) and 3D-US (anterior EAS length r_s = -0.22, 95% CI = (-0.34, -0.09), P = .001). The relationships between SMIS and HRAM had a greater effect size in those with urge-predominant symptoms (resting pressure: r_s = -0.40, 95% CI = (-0.57, -0.20), P < .001, squeeze pressure: r_s = -0.34, 95% CI = (-0.52, -0.12), P = .003). Overall, the variance in SMIS accounted for by anorectal investigations was 8.6% (R² = 0.098, adjusted R² = 0.086, P < .001).

CONCLUSIONS AND INFERENCES

Anorectal investigations are not strong predictors of FI severity. These findings may reflect the multifactorial, heterogeneous pathophysiology of FI, the limitations of the SMIS and anorectal investigations, and contributing factors extrinsic to the anorectum.

Performance, acceptability, and validation of a phone application bowel diary

AIMS

To assess performance, acceptability, external validity, and reliability of a phone application electronic bowel diary (PFDN Bowel eDiary).

METHODS

Women reporting refractory accidental bowel leakage (ABL) were enrolled in a randomized, crossover trial evaluating paper versus eDiary documentation of bowel movements (BM) and fecal incontinence episodes (FIE). Events were characterized by the presence or absence of urgency and Bristol stool scale consistency. The eDiary entries were date/time stamped and prompted by twice-daily phone notifications. Women were randomized to complete up to three consecutive 14-day diaries in two sequences. Diary events were compared between formats using the Pearson correlation. System usability scale (SUS) assessed eDiary usability. The eDiary test-retest reliability was assessed with intraclass correlations (ICCs).

RESULTS

Paired diary data were available from 60/69 (87%) women 63.8 ± 9.8 years old with mean 13.2 BM per week and 6.5 FIE per week (nearly half with urgency). Among those providing diaries, adherence did not differ by paper or eDiary (93.3% vs. 95.0%). Notifications prompted 29.6% of eDiary entries, improving adherence from 70% to 95%. Paper and eDiaries were moderate to-strongly correlated for BMs per week (r = .61), urgency BMs per week (r = .76), FIE per week (r = .66), urgency FIE per week (r = .72). Test-retest reliability was good (ICC = .81 BMs per week, .79 urgency BMs per week, .74 FIE per week, and .62 urgency FIE per week). The mean SUS score was high, 82.3 ± 17.5 (range, 0-100) with 91.4% rating it easy to use, and 75.9% preferring the eDiary over paper.

CONCLUSION

The PFDN Bowel eDiary correlated well with paper diary was considered easy to use, preferred to paper diaries, had high rates of confirmed real-time diary completion that obviated staff data entry.

Relationships between the results of anorectal investigations and symptom severity in patients with faecal incontinence

PURPOSE

Anorectal dysfunction is the focus of diagnostic investigations for faecal incontinence. However, severity of incontinence and anorectal investigation results can be discordant. The aim of this study was to define the relationships between anorectal investigation results and incontinence severity to determine which measures, if any, were predictive of incontinence severity.

METHODS

Patients presenting for investigation of faecal incontinence completed a symptom questionnaire, anorectal manometry, rectal sensation, pudendal nerve terminal motor latency, and endoanal ultrasound. Bivariate analyses were conducted between the Jorge-Wexner score and investigation results. Subgroup analyses were performed for gender and symptom subtypes (urge, passive, mixed). A multiple regression analysis was performed.

RESULTS

Five hundred and thirty-eight patients were included. There were weak correlations between the Jorge-Wexner score and maximal squeeze pressure [r = - 0.24, 95%CI(- 0.31, - 0.16), p < 0.001], and resting pressure [r = - 0.18, (95%CI(- 0.26, - 0.10), p < 0.001]. In men only, there were significant associations between the Jorge-Wexner score and endoanal sonography [IAS defects: t(113) = - 2.26, p = 0.03, d = 0.58, 95%CI(- 4.38, - 0.29)] and rectal sensation (MTV: r_s = - 0.24, 95%CI(- 0.41, - 0.06), p = 0.01). No substantial differences were observed in the urge/passive/mixed subgroup analyses. Multiple regression analysis included three variables: age (β = 0.02, p = 0.17), maximal resting pressure (β = - 0.01, p = 0.28), and maximal squeeze pressure (β = - 0.01, p < 0.01). The variance in the Jorge-Wexner score accounted for by this model was < 10%, (R² = 0.07, p = < 0.01, adjusted R² = 0.06).

CONCLUSION

Anorectal investigations cannot predict the severity of faecal incontinence. This may be due to limitations of diagnostic modalities, the heterogeneity of anorectal dysfunction in these patients, or contributing factors which are extrinsic to the anorectum.

Supervised pelvic floor muscle training versus attention-control massage treatment in patients with faecal incontinence: Statistical analysis plan for a randomised controlled trial

Introduction

Faecal incontinence affects approximately 8–9% of the adult population. The condition is surrounded by taboo; it can have a devastating impact on quality of life and lead to major limitations in daily life. Pelvic floor muscle training in combination with information and fibre supplements is recommended as first-line treatment for faecal incontinence. Despite this, the effect of pelvic floor muscle training for faecal incontinence is unclear. No previous trials have investigated the efficacy of supervised pelvic floor muscle training in combination with conservative treatment and compared this to an attention-control massage treatment including conservative treatment. The aim of this trial is to investigate if 16 weeks of supervised pelvic floor muscle training in combination with conservative treatment is superior to attention-control massage treatment and conservative treatment in patients with faecal incontinence.

Design

Randomised, controlled, superiority trial with two parallel arms.

Methods

100 participants with faecal incontinence will be randomised to either (1) individually supervised pelvic floor muscle training and conservative treatment or (2) attention-control massage treatment and conservative treatment. The primary outcome is participants' rating of symptom changes after 16 weeks of treatment using the Patient Global Impression of Improvement Scale. Secondary outcomes are the Vaizey Incontinence Score, the Fecal Incontinence Severity Index, the Fecal Incontinence Quality of Life Scale, a 14-day bowel diary, anorectal manometry and rectal capacity measurements. Follow-up assessment at 36 months will be conducted.

Discussion

This paper describes and discusses the rationale, the methods and in particular the statistical analysis plan of this trial.

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.

Psychometric evaluation of an online and paper accidental bowel leakage questionnaire: The ICIQ-B questionnaire

AIMS

To evaluate the psychometric properties of an online versus paper US-English version of the International Consultation on Incontinence Questionnaire-Bowel (ICIQ-B).

METHODS

The ICIQ-B includes 17 items under 3 domains: bowel pattern (5 items), bowel control (7 items), and quality of life (5 items). We recruited community-dwelling adults seeking treatment for ≥monthly bowel leakage from specialty clinics within a VA medical center and university affiliate. An online versus paper version was evaluated at baseline, 2 weeks later, and 3 months after nonsurgical treatments per usual care. We assessed test-retest reliability (Pearson correlations) at 2 weeks, internal consistency (Cronbach's alpha), and convergent validity (Pearson correlations). Sensitivity to change was the difference between the baseline and post-treatment (3-month) scores.

RESULTS

Mean age was 58.0 ± 11.9; 36% Veterans, 52% women. At baseline, 2 weeks, and 3 months, we found no differences in the online vs paper scores for the bowel control and quality of life domains. The ICIQ-B demonstrated fair internal consistency for the bowel pattern domain (Cronbach's α = 0.36-0.54). Internal consistency on the bowel pattern domain was better with the paper version than the online version at 2 weeks (P < 0.05) and 3 months (P < 0.01) with no difference at baseline. All other domains had good internal consistency (Cronbach's α > 0.80), good retest reliability (r ≥ 0.70, P < 0.001), domain-specific convergent validity for stool consistency (P < 0.05), incontinence severity (P ≤ 0.002), and quality of life impact (P < 0.05). After nonsurgical treatments, we found a reasonable response to change (P ≤ 0.05).

CONCLUSIONS

Online and paper versions had robust psychometric data for use among U.S. men and women, including Veterans. Neurourol. Urodynam. 36:166-170, 2017. © 2015 Wiley Periodicals, Inc.

Sacral nerve stimulation versus percutaneous posterior tibial nerve stimulation in the treatment of severe fecal incontinence in men

BACKGROUND

Sacral nerve stimulation and percutaneous posterior tibial nerve stimulation have been described previously as effective treatments for fecal incontinence. Nevertheless, there does not exist any study that compares the efficiency of both. The aim of this study was to compare the use of SNS and PPTNS in males with FI.

METHODS

We conducted a prospective cohort study on men with FI treated with SNS or PTNS in the Coloproctology Unit of the University General Hospital of Elche and Reina Sofia of Murcia between January 2010 and December 2011. Preoperative assessment included physical examination, anorectal manometry, and anal endosonography. Anal continence was evaluated using the Wexner continence grading system. Quality of life was evaluated using the Fecal Incontinence Quality of life Scale.

RESULTS

Nineteen patients were included (ten patients SNS and nine PPTNS). SNS improved FI in nine of the ten patients. The mean Wexner score decreased significantly from a median of 14 (12-16) (preoperative) to 4 (1-8) (6-month revision) (p = 0.007). PTNS improved FI in seven of the nine patients. The mean Wexner score decreased significantly from a median of 12 (11-19) (preoperative) to 5 (4-7) (6-month revision) (p = 0.018). Both treatments produced symptomatic improvement without statistical differences between them.

CONCLUSIONS

Our study was nonrandomized with a relatively small number of patients. PPTNS had similar efficiency to the SNS in our men population. However, more studies are necessary to exclude selection bias and analyze long-term results.

Validation of a new scoring system: Rapid assessment faecal incontinence score

AIM: To implement a quick and simple test - rapid assessment faecal incontinence score (RAFIS) and show its reliability and validity.

METHODS: From March 2008 through March 2010, we evaluated a total of 261 consecutive patients, including 53 patients with faecal incontinence. Demographic and comorbidity information was collected. In a single visit, patients were administered the RAFIS. The results obtained with the new score were compared with those of both Wexner score and faecal incontinence quality of life scale (FIQL) questionnaire. The patient without influence of the surgeon completed the test. The role of surgeon was explaining the meaning of each section and how he had to fill. Reliability of the RAFIS score was measured using intra-observer agreement and Cronbach’s alpha (internal consistency) coefficient. Multivariate analysis of the main components within the different scores was performed in order to determine whether all the scores measured the same factor and to conclude whether the information could be encompassed in a single factor. A sample size of 50 patients with faecal incontinence was estimated to be enough to detect a correlation of 0.55 or better at 5% level of significance with 80% power.

RESULTS: We analysed the results obtained by 53 consecutive patients with faecal incontinence (median age 61.55 ± 12.49 years) in the three scoring systems. A total of 208 healthy volunteers (median age 58.41 ± 18.41 years) without faecal incontinence were included in the study as negative controls. Pearson’s correlation coefficient between “state” and “leaks” was excellent (r = 0.92, P < 0.005). Internal consistency in the comparison of “state” and “leaks” yielded also excellent correlation (Cronbach’s α = 0.93). Results in each score were compared using regression analysis and a correlation value of r = 0.98 was obtained with Wexner score. As regards FIQL questionnaire, the values of “r” for the different subscales of the questionnaire were: “lifestyle”r = -0.87, “coping/behaviour”r = -0.91, “depression”r = -0.36 and “embarrassment”r = -0.90, (P < 0.01). A multivariate analysis showed that all the scoring systems measured the same factor. A single factor may explain 80.84% of the variability of FI, so all the scoring systems measure the same factor. Patient’s continence improves when RAFIS and Jorge-Wexner scores show low values and when the values obtained in the FIQL questionnaire are high.

CONCLUSION: RAFIS is a valid and reliable tool to assess Faecal Incontinence.

Predictors of fecal incontinence and related quality of life after a total mesorectal excision with primary anastomosis for patients with rectal cancer

Purpose

After total mesorectal excision (TME) with primary anastomosis for patients with rectal cancer, the quality of life (QoL) may be decreased due to fecal incontinence. This study aimed to identify predictors of fecal incontinence and related QoL.

Methods

Patients who underwent TME with primary anastomosis for rectal cancer between December 2008 and June 2012 completed the fecal incontinence quality of life scale (FIQoL) and Wexner incontinence score. Factors associated with these scores were identified using a linear regression analysis.

Results

A total of 80 patients were included. Multivariate analysis identified a diverting ileostomy (n = 58) as an independent predictor of an unfavorable outcome on the FIQoL subscale coping/behavior (P = 0.041). Ileostomy closure within and after 3 months resulted in median Wexner scores of 5.0 (interquartile range [IQR], 2.5-8.0) and 10.5 (IQR, 6.0-13.8), respectively (P < 0.001). The median FIQoL score was 15.0 (IQR, 13.1-16.0) for stoma closure within 3 months versus 12.0 (IQR, 10.5-13.9) for closure after 3 months (P = 0.001).

Conclusion

A diverting ileostomy is a predictor for an impaired FIQoL after a TME for rectal cancer. Stoma reversal within 3 months showed better outcomes than reversal after 3 months. Patients with a diverting ileostomy should be informed about the impaired QoL, even after stoma closure.

Systematic Review: Aesthetic Assessment of Breast Reconstruction Outcomes by Healthcare Professionals

BACKGROUND

Achieving an aesthetic outcome following postmastectomy breast reconstruction is both an important goal for the patient and plastic surgeon. However, there is currently an absence of a widely accepted, standardized, and validated professional aesthetic assessment scale following postmastectomy breast reconstruction.

METHODS

A systematic review was performed to identify all articles that provided professional assessment of the aesthetic outcome following postmastectomy, implant- or autologous tissue-based breast reconstruction. A modified version of the Scientific Advisory Committee's Medical Outcomes Trust (MOT) criteria was used to evaluate all professional aesthetic assessment scales identified by our systematic review. The criteria included conceptual framework formation, reliability, validity, responsiveness, interpretability, burden, and correlation with patient-reported outcomes.

RESULTS

A total of 120 articles were identified: 52 described autologous breast reconstruction, 37 implant-based reconstruction, and 29 both. Of the 12 different professional aesthetic assessment scales that exist in the literature, the most commonly used scale was the four-point professional aesthetic assessment scale. The highest score on the modified MOT criteria was assigned to the ten-point professional aesthetic assessment scale. However, this scale has limited clinical usefulness due to its poor responsiveness to change, lack of interpretability, and wide range of intra- and inter-rater agreements (Veiga et al. in Ann Plast Surg 48(5):515-520, 2002).

CONCLUSIONS

A "gold standard" professional aesthetic assessment scale needs to be developed to enhance the comparability of breast reconstruction results across techniques, surgeons, and studies to aid with the selection of procedures that produce the best aesthetic results from both the perspectives of the surgeon and patients.

Management of Loose, Frequent Stools and Fecal Incontinence in a Chronic Mesenteric Ischemia Patient with Oral Serum-derived Bovine Immunoglobulin

AIM

Chronic diarrhea with fecal incontinence (FI) is a severe, underreported, and intractable problem in many patients for which limited pharmaceutical options exist.

METHODS

A retrospective case history was collected after the administration of a prescription medical food composed of serum-derived bovine immunoglobulin/protein isolate (SBI) at 5 g once daily in a patient with chronic mesenteric ischemia (CMI) for chronic loose, frequent, and urgent stools. The patient was an 84-year-old white male with a 20-year history of progressively worsening chronic diarrhea with six to eight watery stools per day (Bristol Stool Form Scale, Type 7), urgency, nocturnal diarrhea, FI, and postprandial abdominal discomfort before administration of SBI.

RESULTS

After four weeks of SBI administration, the patient had two to three soft, semi-formed stools (Bristol Stool Form Scale, Types 4 and 5) per day with no nocturnal diarrhea, urgency, or FI, as well as full resolution of abdominal discomfort. In addition, the patient expressed an enhanced quality of life (QoL): able to travel, attend social events, and perform tasks not possible before therapy.

CONCLUSION

This case underscores how a safe, nutritional therapy may offer a new modality for physicians to address chronic loose, frequent stools with FI in patients with CMI in this difficult to manage gastrointestinal population.

Study of anorectal function after transanal endoscopic surgery

AIM

To evaluate the impact of Transanal Endoscopic Microsurgery (TEM) on anorectal function, using clinical and manometric assessments. To identify subgroups likely to develop incontinence after TEM, by stratifying the sample.

METHOD

Descriptive, prospective study. Between December 2004 and May 2011, 222 patients were operated on at our hospital, of whom 21 were excluded from the study. Patients underwent anal manometry and answered a clinical incontinence questionnaire (the Wexner scale) prior to surgery, one month post-surgery, and then at four months post-surgery.

RESULTS

There were no statistically significant differences between preoperative Wexner questionnaire scores and values at one month and four months post-surgery. Preoperative baseline pressure (BP) values were 64 mmHg±26.18, falling to 44.26 mmHg±20.11 at one month and to 48.86 mmHg±21.14 at four months. Voluntary Contraction Pressure (VCP) reached preoperative values of 200.49 mmHg±88.85, falling to 169.5 mmHg±84.95 and to 173.6±79 at four months. The differences in BP and VCP were statistically significant. The sample was stratified in order to identify subsets susceptible to incontinence after surgery, but no at-risk subgroups were found. Multivariate analysis did not detect any predictors of incontinence.

CONCLUSION

The sustained, controlled anal dilatation produced with TEM caused statistically significant decreases in VCP and BP one month and four months after surgery. However, the Wexner questionnaire scores did not show any association with clinical incontinence. No predictors of postoperative incontinence were observed. We conclude that TEM is a safe technique and does not affect continence.

Predictive factors for successful sacral nerve stimulation in the treatment of fecal incontinence: lessons from a comprehensive treatment assessment

BACKGROUND

Sacral nerve stimulation has a place in the treatment algorithm for fecal incontinence, but the predictive factors of its midterm and long-term success are unknown.

OBJECTIVE

The purpose of this study was to investigate the effect of a 3-year sacral nerve stimulation treatment of fecal continence and to identify specific predictive factors from the pretreatment and per-treatment assessments for the midterm success of sacral nerve stimulation.

DESIGN

A cohort analysis of consecutive patients treated with sacral nerve stimulation for fecal incontinence over a period of 3 years was performed.

SETTINGS

This study was conducted at an academic colorectal unit in a tertiary care center.

PATIENTS

Sixty patients were available for the assessment of 3-year outcomes.

MAIN OUTCOME MEASURES

Clinical outcome (including Cleveland Clinic score) and anorectal physiological data were collected prospectively before and after treatment.

RESULTS

At the 3-year follow-up, 33 of the 60 implanted patients had an improved outcome as defined by a ≥30% improvement in the Cleveland Clinic score from baseline (37.1% on intention to treat and 55.0% per protocol), whereas 22 had an unsuccessful outcome as defined by a <30% improvement in the Cleveland Clinic score from baseline (24.7% on intention to treat and 36.7% per protocol), of whom 7 had their device explanted or switched off permanently before the 3-year assessment, and 3 were lost at follow-up. At 3 years, we failed to identify any factors that could predict the 3-year clinical outcome of sacral nerve stimulation based on preimplantation and postimplantation assessments.

LIMITATIONS

This study involved a relatively small number of patients. There was a lack of consistency in the tool used to evaluate the efficacy of the test and permanent stimulations.

CONCLUSIONS

Based on per-protocol assessments, 55% of the patients had improved outcomes at the 3-year follow-up. No predictor was identified by the pretreatment and posttreatment assessments (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A133).

The test-retest reliability of fecal incontinence severity and quality-of-life assessment tools

BACKGROUND

The St. Mark's score and Cleveland Clinic score are widely used for assessing the severity of fecal incontinence, whereas the Rockwood quality of life scale is used to evaluate the impact on the quality of life of patients.

OBJECTIVE

The aim of this study was to determine the intra- and interobserver reliability of these assessment tools.

DESIGN

All patients were recruited prospectively. To assess intraobserver reliability each patient was asked to complete 4 assessments (the St. Mark's and Cleveland Clinic scores, the Rockwood scale, and a visual analog scale) at 2 time points: initially at recruitment (P1) and then 6 weeks later (P2). No alteration to medications or treatment occurred during this interval. For interobserver reliability, the St. Mark's and Cleveland Clinic scores were also completed by a physician (time point P1) and a nurse (time point P2).

OUTCOME MEASURES

Intra- and interobserver reliability were determined by using an intraclass correlation coefficient. An intraclass correlation coefficient value of less than 0.40 indicates poor reliability, values in the range 0.40 to 0.75 indicate fair to good reliability, and a value of greater than 0.75 shows excellent reliability.

RESULTS

Thirty-nine patients (34 female) with a median age of 65 years were studied. The intraclass correlation coefficient for intraobserver reliability for the Cleveland Clinic score at time points P1 and P2 was 0.858 (95% CI, 0.611-0.940); and for St. Mark's score, the intraclass correlation coefficient was 0.823 (95% CI, 0.556-0.922). The intraclass correlation coefficients for the quality-of-life domains ranged between 0.864 and 0.938, whereas the intraclass correlation coefficient for the visual analog scale was 0.958 (95% CI, 0.906-0.982). The interobserver reliability ranged from 0.795 to 0.945 for the Cleveland Clinic score and from 0.793 to 0.939 for the St. Mark's score.

LIMITATIONS

Of the 39 patients recruited, only 31 patients completed the second assessment at time point P2. This increases the risk of nonresponse error in this study, which is a recognized limitation of mail-mode surveys.

CONCLUSION

Current assessment tools for the severity of fecal incontinence and its impact on quality of life have an excellent intra- and interobserver reliability and remain a good objective measure of patients' symptoms (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A135).

Perineal retraining improves conservative treatment for faecal incontinence: a multicentre randomized study

BACKGROUND

Anal incontinence is a frequent complaint that profoundly affects quality of life. Our aim was to determine whether perineal retraining gives additional benefits to standard medical treatment.

METHODS

Patients with anal incontinence and a Wexner score >4 were randomly assigned to standard conservative treatment (control) or perineal retraining, including biofeedback, in addition to standard treatments (biofeedback). Diaries, self-administered questionnaires and satisfaction scores quantified the benefits. Self-evaluated improvement was the primary outcome measure. A score ≥3 (in an improvement scale from -5 to +5) defined success.

RESULTS

Overall, 157 patients were included; 80 in the control group (75% females, mean age 60.1 ± 13.2 years) and 77 in the biofeedback group (79% females, mean age 61.9 ± 10.2 years). After a 4-month follow-up, the success rate was significantly higher in the biofeedback group (57% versus 37%; p<0.021). In the biofeedback group, daily stool frequency, leakage, and faecal urgency significantly decreased, and daily non-urgent perception of stool increased. Conversely, symptomatic scores and quality of life scales did not significantly differ between groups. In a multivariate model, the adjusted odds ratio showed that perineal retraining was significantly associated with a higher chance of self-rated improvement (adjusted Odd Ratio [95%CI]: 2.34 [1.14-4.80]; p=0.021).

CONCLUSIONS

Perineal retraining offers a moderate but significant benefit for patients suffering from anal incontinence.

Correlation between fecal incontinence and quality of life after low anterior resection for rectal cancer

SUMMARY Aim: The purpose of this study was to investigate the correlation between fecal incontinence and quality of life after low anterior resection and long-term follow-up. Methods: For 72 patients with coloanal or low colorectal anastomosis, the quality of life was determined by the European Organisation for Research and Treatment of Cancer (EORTC) questionnaires C-30 and CR-38. The Vaizey score was used for assessment of fecal incontinence. Results: The risk of fecal incontinence significantly increased with a lower level of anastomosis (p < 0.001). The QLQ CR-38 did not discern differences between patients. The OLQ C-30 only found significantly worse social and role function in patients with coloanal anastomosis. There was a weak correlation between fecal incontinence and quality of life only. Conclusion: Determination of quality of life by EORTC QLQ C-30 and CR-38 cannot replace measurement of functional outcome. Severity of fecal incontinence and quality of life should be determined separately for assessment of functional outcome after low anterior resection.

Severity of fecal urgency and incontinence in inflammatory bowel disease: clinical, manometric and sonographic predictors

BACKGROUND

Fecal incontinence (FI) and urgency are prevalent symptoms in patients with inflammatory bowel diseases (IBD). It is unclear which factors determine their severity. We evaluated associations of clinical activity, anorectal motility, and endoanal sonography with FI severity in IBD.

METHODS

Fifty-eight consecutive IBD patients and 14 healthy volunteers participated in a cross-sectional, tertiary-center study. Active disease was defined as Crohn's disease activity index ≥ 150 and as simple clinical colitis index > 2. We assessed anal pressures and fatigue rate index (FRI) of the external anal sphincter (EAS) by manometry, rectal compliance and sensitivity by balloon distension, and sphincter defects by endoanal ultrasound. Significant bivariate associations between these parameters and the fecal incontinence severity scale (FISS) were evaluated in multivariate analysis.

RESULTS

Twenty-seven patients (47%) reported urgency, 13 of which (22%) reported FI. Defects of the internal anal sphincter (IAS) and the EAS were diagnosed in 14 (24%) and 13 patients (22%), respectively. Patients had significantly lower rectal compliance and FRI compared with controls. FISS demonstrated significant bivariate associations with clinical disease activity (P = 0.0115), FRI (P = 0.0018), sonographic IAS and EAS defects (P < 0.0001 and 0.0059), rectal compliance (P = 0.0001), and volume at the threshold of a constant urge (Vurge, P = 0.0002). In multivariate analysis, FISS was associated with clinical disease activity (P = 0.0325), FRI (P = 0.0367), Vurge (P = 0.0091), and sonographic IAS defect(s) (P = 0.0008). The derived model explained 62% of the variance in FISS (P < 0.0001).

CONCLUSIONS

Clinical disease activity and manometric and sonographic anorectal parameters are associated with FI severity in IBD. Prospective studies are warranted to evaluate their predictive value in continence outcomes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A systematic review of psychometric evidence and expert opinion regarding the assessment of faecal incontinence in older community-dwelling adults

Objectives  This review had two objectives: (i) to determine what is required in an assessment of faecal incontinence issues for older community-dwelling adults; and (ii) to determine the psychometric tools most effective for assessment of faecal incontinence in older community-dwelling adults. Inclusion criteria  For the review of psychometric tools, studies were included if they were concerned with people living in the community, included a significant proportion of the sample aged 65 years or over, and either examined psychometric properties of assessment tools or assessed sensitivity of assessment tools to non-surgical interventions available in the community setting. For the review of expert opinion, the search was limited to expert opinion provided by an expert in faecal incontinence that related to community-based assessment. Only articles published in English were eligible for inclusion and no limits were placed on publication dates. Search strategy  An initial search of Medline and CINAHL databases identified terminology frequently used in the literature with regard to assessment of faecal incontinence. An extensive search was then undertaken using all identified key words and index terms. The third step involved a search of reference lists and bibliographies of all relevant articles. Methodological quality  All identified studies that met the inclusion criteria were assessed for methodological validity in the case of studies considered for inclusion in the psychometric review. Validity of expert text was also assessed prior to it being included in the review. Results  The final search strategy identified approximately 7000 references. Full-text versions of 144 references were critically appraised for inclusion in the review. Of these, 25 sources were included in the review of expert opinion and 16 in the review of psychometric properties. In the review of expert opinion, 254 conclusions were extracted for synthesis. The 31 thematic categories were organised under five major themes: History-taking, bowel assessment, psychosocial aspects, physical examination and specialist referral. From the sources that survived critical appraisal, 52 conclusions relating to psychometric properties of assessment tools were derived. There was limited, if any, analysis of psychometric properties for the majority of assessment tools. The Wexner and Vaizey symptom severity scales demonstrated acceptable test-retest reliability and convergent validity. The Fecal Incontinence Quality of Life Scale (FIQLS) demonstrated reasonable reliability and good convergent and criterion-related validity. There was, however, some evidence questioning its discriminant validity. Conclusions  This systematic review represents an important first stage in developing guidelines for assessment of faecal incontinence in community-dwelling older people. Assessment should be comprehensive in nature. Gaps in expert opinion are evident regarding issues such as assessment of cognitive decline and specialist referral. Continence advisors need to be appropriately trained in using and interpreting results from assessment tools and conducting physical examinations. Although studies in the review of psychometric properties suffer from limitations such as inadequate sample sizes, the Vaizey and Wexner scales would appear to be the tools of choice. The FIQLS is clearly the tool of choice at this stage for measuring faecal incontinence quality of life. Further validation of tests used in faecal incontinence assessments is required.

Excisional hemorrhoidal surgery and its effect on anal continence

AIM: To investigate the role of anal cushions in hemorrhoidectomy and its effect on anal continence of the patients.

METHODS: Seventy-six consecutive patients (33 men and 43 women) with a mean age of 44 years were included. They underwent Milligan-Morgan hemorrhoidectomy because of symptomatic third- and fourth-degree hemorrhoids and failure in conservative treatment for years. Wexner score was recorded and liquid continence test was performed for each patient before and two months after operation using the techniques described in our previous work. The speed-constant rectal lavage apparatus was prepared in our laboratory. The device could output a pulsed and speed-constant saline stream with a high pressure, which is capable of overcoming any rectal resistance change. The patients were divided into three groups, group A (< 900 mL), group B (900-1200 mL) and group C (> 1200 mL) according to the results of the preoperative liquid continence test.

RESULTS: All the patients completed the study. The average number of hemorrhoidal masses excised was 2.4. Most patients presented with hemorrhoidal symptoms for more than one year, including a mean duration of incontinence of 5.2 years. The most common symptoms before surgery were anal bleeding (n = 55), prolapsed lesion (n = 34), anal pain (n = 12) and constipation (n = 17). There were grade III hemorrhoids in 39 (51.3%) patients, and grade IV in 37 (48.7%) patients according to Goligher classification. Five patients had experienced hemorrhoid surgery at least once. Compared with postoperative results, the retained volume in the preoperative liquid continence test was higher in 40 patients, lower in 27 patients, and similar in the other 9 patients. The overall preoperative retained volume in the liquid continence test was 1130.61 ± 78.35 mL, and postoperative volume was slightly decreased (991.27 ± 42.77 mL), but there was no significant difference (P = 0.057). Difference was significant in the test value before and after hemorrhoidectomy in group A (858.24 ± 32.01 mL vs 574.18 ± 60.28 mL, P = 0.011), but no obvious difference was noted in group B or group C. There was no significant difference in Wexner score before and after operation (1.68 ± 0.13 vs 2.10 ± 0.17, P = 0.064). By further stratified analysis, there was significant difference before and 2 months after operation in group A (2.71 ± 0.30 vs 3.58 ± 0.40, P = 0.003). In contrast, there were no significant differences in group B or group C (1.89 ± 0.15 vs 2.11 ± 0.19, P = 0.179; 0.98 ± 0.11 vs 1.34 ± 0.19, P = 0.123).

CONCLUSION: There is no difference in the continence status of patients before and after Milligan-Morgan hemorrhoidectomy. However, patients with preoperative compromised continence may have further deterioration of their continence, hence Milligan-Morgan hemorrhoidectomy should be avoided in such patients.

Long-term outcomes of anal sphincter repair for fecal incontinence: a systematic review

BACKGROUND

Thorough and objective analysis of long-term results following anal sphincter repair for fecal incontinence will permit the correct application of this operation in the context of newer treatment methods.

OBJECTIVE

This investigation aimed to comprehensively review outcomes beyond 5 years in patients undergoing anal sphincter repair for fecal incontinence.

DATA SOURCES

A systematic review of Embase and MEDLINE articles published between January 1991 and December 2010 was conducted; additional studies were identified by hand-searching bibliographies.

STUDY SELECTION

A 2-step process was used for screening articles examining sphincter repair or sphincteroplasty in adults with fecal incontinence, with a minimum follow-up of 60 months.

MAIN OUTCOME MEASURES

Subjective or objective assessment of fecal incontinence in the postoperative period was completed.

RESULTS

Data from 16 studies were examined, comprising nearly 900 repairs. There was significant heterogeneity in outcome measures, although most articles utilized at least one established incontinence instrument. In general, most series reported an initial subjectively "good" outcome in the majority of patients, with declines in this proportion over longer follow-up. There was poor correlation between quality of life and the severity of fecal incontinence, with all articles reporting high overall patient satisfaction even if continence declined with time or adaptive measures were needed. No consistent predictive factors for failure were identified.

LIMITATIONS

This study was limited by the paucity of level I data with an adequate length of follow-up.

CONCLUSION

Despite worsening results over time, most patients remain satisfied with their surgical outcome postsphincteroplasty. Efforts should be directed at identifying patients who may do poorly following sphincter repair, as well as establishing standardized long-term outcome benchmarks for comparing novel techniques for treating fecal incontinence.

Comparative analysis of summary scoring systems in measuring fecal incontinence

Purpose

For measuring symptoms of fecal incontinence, summary scoring systems are widely used, but rigorous psychometric validation or assessment of such systems in terms of patients' subjective perception has rarely been done to date. This study was designed to assess the correlation between each severity measure and patients' subjective perception or clinicians' clinical assessment. We attempted to compare summary scoring systems of severity measures and searched for which of them showed higher validity among them.

Methods

Consecutive patients who visited our clinic with fecal incontinence were prospectively evaluated. A total of 43 patients were included. Four summary scoring systems were chosen for comparison: the Rothenberger, Wexner, Vaizey and Fecal Incontinence Severity Index systems. They are correlated with subjective perception scores by patients, and also with clinical assessment scores by investigators.

Results

There was no significant difference between clinical scores of two investigators (paired t-test, P = 0.988). Inter-observer reliability was 0.95 (Intra-class correlation coefficient, 95% confidence interval 0.91 to 0.98). Significant correlations were proved between patients' subjective perception scores and all the summary scoring systems, and also between the mean clinical scores and all the summary scoring systems. The highest was with the Wexner scale (r = 0.66, P < 0.001) (r = 0.70, P < 0.001), and the lowest was with the Rothenberger scale (r = 0.58, P < 0.001) (r = 0.61, P < 0.001) in both correlations.

Conclusion

The Wexner scale correlates the most closely with subjective perception of severity of symptoms by patients, and also with clinical assessment by investigators. We recommend the Wexner scale among summary scoring systems as a tool for measuring fecal incontinence.

Determining levels of fecal incontinence in the community: a New Zealand cross-sectional study

BACKGROUND

Fecal incontinence is a socially stigmatized condition, and its prevalence in the community has been problematic to quantify because of difficulty with its definition.

OBJECTIVE

This study estimates the community prevalence of fecal incontinence in New Zealand by 3 scales of measurement: patient perceptions of a "problem with bowel control," their symptoms, and their quality of life. DESIGN/MAIN OUTCOME MEASURES: A postal survey of 2000 people, aged >18, randomly selected from the national electoral roll, was performed. This used a validated, reliability-tested, anonymous questionnaire, the Comprehensive Fecal Incontinence Questionnaire, incorporating the identification of a "problem with bowel control," the Fecal Incontinence Severity Index, and the Fecal Incontinence Quality of Life Scale.

RESULTS

The response rate was 68.7%. A total of 14.7% (95% CI: 12.6-16.7) of participants "felt they had a problem with bowel control" and 12.4% (95% CI: 10.5-14.5) had fecal incontinence when defined using the Fecal Incontinence Severity Index table as "leakage of liquid or solid stool ≥ 1/month." In terms of quality of life, 26.8% of the population (95% CI: 24.2-29.4) noted some impairment on the Fecal Incontinence Quality of Life Scale. In total, 155 (13.2%) participants reported at least 2 of the 3 possible diagnostic measures, and this may provide a way to incorporate the 3 measures into a new definition of fecal incontinence.

LIMITATIONS

This study incorporated a new "generic" question enquiring about an individual's perception of a bowel control problem and also introduced a "cutoff" value for Fecal Incontinence Quality of Life Scale to attempt to identify those with any impairment "due to accidental bowel leakage."

CONCLUSIONS

This study helps to highlight some of the challenges involved with suitably identifying those who have fecal incontinence within the community. The prevalence rate of 13.2% represents a realistic measure of the burden of fecal incontinence in the general population, and further research in this area is recommended.

Prevalence of faecal incontinence and analysis of its impact on quality of life and mental health

AIM

Faecal incontinence is a significant healthcare problem, with an estimated prevalence of up to 5% of the general population. Little is known about its prevalence among patients attending primary care.

METHOD

A cross-sectional multicentre study was undertaken. Adult patients attending 10 primary health centres were interviewed. Faecal incontinence was defined as involuntary leakage of flatus, liquid or solid stool at least once in the preceding 4 weeks. Health-related and disease-specific quality of life was assessed using the 36-item Short-Form Health Survey and the Fecal Incontinence Quality of Life scale, respectively. Mental health status was assessed using the 28-item General Health Questionnaire. An adjusted multivariate analysis was performed to study the association of faecal incontinence with the presence of altered mental health status.

RESULTS

A total of 518 subjects (mean age 60.3 years) were studied. The prevalence of faecal incontinence was 10.8%. Altered mental health status was found in 51.8% of patients with faecal incontinence and in 30.5% of those without (P = 0.001). Faecal incontinence was a significant independent factor for altered mental health status (odds ratio, 2.088; 95% CI 1.138-3.829; P = 0.017).

CONCLUSION

The prevalence of faecal incontinence in primary care is high, with a significant impact on quality of life and mental health status.

Sacral nerve stimulation for fecal incontinence: long-term outcomes

BACKGROUND

Numerous studies advocate the short-term benefits of sacral nerve stimulation for fecal incontinence, but there has been a paucity of studies on longer-term outcomes.

OBJECTIVE

The objective of this study was to report the long-term outcome of sacral nerve stimulation performed for fecal incontinence at a single institution.

PATIENTS AND DESIGN

Between January 2004 and May 2007, 53 patients underwent definitive sacral nerve stimulation for fecal incontinence at our institution. Prospectively recorded baseline information, including Wexner incontinence scores and standard short-form (SF-12) health survey scores, were compared with scores at follow-up.

RESULTS

Forty-one patients were available for long-term follow-up with a mean duration of 51 months. The median Wexner score decreased from a baseline of 11.5 (range, 3.0-18.0) to 8.0 (range, 0.0-18.0) at follow-up. The mean difference in Wexner score was 2.7 (P < .001). There was no statistically significant change in SF-12 physical scores, but a small but highly significant change occurred in SF-12 mental scores. The median SF-12 mental domain score was 49.5 (range, 15.0-62.1) at baseline, and 57.0 (range, 20.0-64.0) at follow-up, with a mean difference of 4.5 (P = .006). Subgroup analysis performed comparing patients with or without prior intersphincteric silicon biomaterial implants demonstrated a mean difference in Wexner score of -3.5 (no implant) vs 0.0 (previous implant), with P < .09 (not statistically significant).

CONCLUSIONS

Sacral nerve stimulation results in a statistically significant improvement in fecal incontinence scores in the long term.

Predictive factors for successful sacral nerve stimulation in the treatment of faecal incontinence: results of trial stimulation in 200 patients

AIM

Sacral nerve stimulation (SNS) has a place in the treatment algorithm for faecal incontinence (FI). However, after implantation, 15-30% of patients with FI fail to respond for unknown reasons. We investigated the effect of SNS on continence and quality of life (QOL) and tried to identify specific predictive factors of the success of permanent SNS in the treatment of FI.

METHOD

Two hundred consecutive patients (six men; median age = 60; range 16-81) underwent permanent implantation for FI. The severity of FI was evaluated by the Cleveland Clinic Score. Quality of life was evaluated by the French version of the American Society of Colon and Rectal Surgeons (ASCRS) quality of life questionnaire (FIQL). All patients underwent a preoperative evaluation. After permanent implantation, severity and QOL scores were reevaluated after six and 12 months and then once a year.

RESULTS

The severity scores were significantly reduced during SNS (P = 0.001). QOL improved in all domains. At the 6-month follow-up, the clinical outcome of the permanent implant was not affected by age, gender, duration of symptoms, QOL, main causes of FI, anorectal manometry or endoanal ultrasound results. Only loose stool consistency (P = 0.01), persistent FI even though diarrhoea was controlled by medical treatment (P = 0.004), and low stimulation intensity (P = 0.02) were associated with improved short-term outcomes. Multivariate analysis confirmed that loose stool consistency and low stimulation intensity were related to a favourable outcome.

CONCLUSION

Stool consistency and low stimulation intensity have been identified as predictive factors for the short-term outcome of SNS.

Factors impacting quality of life in women with fecal incontinence

PURPOSE

The aim of this study was to characterize differences in health-related quality of life among women presenting for treatment of fecal incontinence.

METHODS

Among 155 women presenting for treatment of fecal incontinence in a specialty clinic, validated questionnaires measured impact on quality of life (Modified Manchester Health Questionnaire) and severity (the Fecal Incontinence Severity Index). Bowel symptoms, including frequency, urgency, and stool consistency, were ascertained. Comorbid diseases were self-reported. Linear regression models were constructed from significant univariate variables to examine differences observed in quality of life scores.

RESULTS

The average age was 58.7 +/- 11.5 years, with no differences found in quality of life scores according to race, body mass index, or number of vaginal deliveries (P > .05). Younger age, increased urinary incontinence symptoms, prior cholecystectomy, prior hysterectomy, and severity of bowel symptoms correlated with a negative impact on quality of life in univariate analysis (P < .05). Average severity scores were 30.5 +/- 13.7, with moderate correlation seen with increasing severity and quality of life scores (R2 = 0.60). After controlling for severity, women had increased quality of life scores with more bowel urgency (15 points; 95% CI, 8.1-21.2), harder stool consistency (10 points; 95% CI, 3.8-16.3), and prior hysterectomy (9 points; 95% CI, 2.7-15.4).

CONCLUSION

Bowel symptoms and having undergone a hysterectomy had the greatest negative impact on quality of life in women seeking treatment for fecal incontinence. Targeting individualized treatments to improve bowel symptoms may improve quality of life for women with fecal incontinence.

Prevalence of faecal incontinence in adults aged 30 years or more in general population

OBJECTIVE

The aim of this study was to estimate the prevalence of and factors associated with faecal incontinence in a Finnish population.

METHOD

A population-based age-stratified random sample of 8000 people aged 30-81 years from a large city was obtained from the national population registry. A postal questionnaire was sent to all subjects. Questions regarding faecal incontinence were adopted from a previously developed validated questionnaire.

RESULTS

Response rate was 39.8%. Overall, the prevalence of faecal incontinence occurring in any frequency within the last year was 10.6% (CI: 9.5-11.6%). Women suffered significantly more often than men (11.9% vs. 8.7%). The prevalence of faecal incontinence occurring at least twice a month was 5.2% (CI: 4.5-6%). Of these subjects, 62.3% used a pad at least twice a month to protect their underwear (91 women, 10 men), 23.6% used it daily. There was a strong correlation between faecal incontinence and urinary incontinence. Of the 162 subjects reporting faecal incontinence at least twice a month, only 27.2% had discussed the problem with their physician. In 12.4%, their physician had raised the question of faecal incontinence. Only 10% had received treatment for it, but 66% (107/162) felt they needed treatment.

CONCLUSION

Faecal incontinence is a common problem. Only a minority had reported this symptom to their physician and surprisingly few had received treatment for it. General awareness of faecal incontinence and treatment options should be improved among primary care physicians and general population.

Effective management of acute faecal incontinence in hospital: review of continence management systems

This paper reviews the scientific literature regarding current systems available for the management of acute faecal incontinence (FI) in hospital patients. The review searched Medline from 1950 to October 2009 using the adapted search strategy, as devised by the Cochrane Incontinence Group, in order to identify studies relevant to this review, yielding 197 records. Ten studies fitted the inclusion criteria with none of the studies being randomised control trials. Characteristics identified from the studies included: duration of the management devices, cost implications, length of patient stay, contraindications and patient assessment. The management of acute FI in acute settings is a relatively ignored problem, with little available evidence to support a standardised approach to its management. The review highlights the need for early identification of contraindications when FI management systems are being used, particularly in patients administered antithrombotic drugs such as aspirin.

Fecal incontinence

Fecal incontinence is a devastating problem for those afflicted. It can lead to embarrassment and social isolation. Treating the problem begins with a thorough history and physical examination. Further testing (such as anal physiology testing or anal endosonography) depends on the examination and treatment plan. Conservative medical therapies (such as dietary manipulation, medication to slow the stool, and biofeedback) are usually tried first. Surgery includes sphincter repair, SECCA, artificial bowel sphincter, and stoma. New therapies continue to evolve with the intention of further improving quality of life for these afflicted patients.

Faecal incontinence after seton treatment for anal fistulae with and without surgical division of internal anal sphincter: a systematic review

OBJECTIVE

The challenge of surgery for anal fistula is to eradicate the fistula track while maintaining anal continence. Seton placement is recommended to reduce postoperative faecal incontinence but interestingly a great range of functional impairment after surgery has been published. The aim of this study was to analyse the influence of intra-operative internal anal sphincter division during tight or cutting seton technique for cryptogenic anal fistula, on the results of recurrence and postoperative faecal incontinence.

METHOD

A systematic literature review was performed to identify published series from 1966 to May 2007 of patients with anal fistula treated by a tight or cutting seton technique. The published series has been divided in to those where preservation of internal anal sphincter was performed (PIAS group) or where intra-operative surgical division was undertaken in the time of seton placement (SIAS group) .The main endpoints of the review were to study anal fistula recurrence rate and postoperative faecal incontinence.

RESULTS

Eighteen studies including 19 series and 448 patients were analysed in detail. Recurrence rate was 5.0% and 3.0% in PIAS and SIAS group respectively. Overall faecal incontinence rate was 5.6% in PIAS group and 25.2% in SIAS group.

CONCLUSION

Although based on low-evidence studies, intra-operative preservation of internal anal sphincter at the time of seton insertion for anal fistula seems to reduce the postoperative faecal incontinence without a substantial increase in recurrence rates.

Impact of fecal incontinence on quality of life

AIM: To explore the impact of fecal incontinence (FI) on quality of life (QOL) of patients attending urogynecology and colorectal clinics (CCs).

METHODS: Cross-sectional study of 154 patients (27 male) with FI, who attended the clinics at a regional hospital in North Queensland, Australia in 2003 and 2004, and completed the Fecal Incontinence Quality of Life Scale (FIQL: 1 = very affected; 4 = not affected).

RESULTS: More than 22% of patients had their QOL affected severely by FI. Patients reported that they had not previously been asked about FI by a medical practitioner nor did they voluntarily disclose its presence. The median FIQL scores for all participants were: lifestyle = 3.24; coping = 2.23; depression = 2.42; and embarrassment = 2.33. Increasing frequency of soiling had a negative effect on all four FIQL scales (P < 0.001) as did the quantity of soiling (P < 0.01). Female CC patients had poorer FIQL scores than urogynecology clinic patients for lifestyle (P = 0.015), coping (P = 0.004) and embarrassment (P = 0.009), but not depression (P = 0.062), despite having experienced FI for a shorter period.

CONCLUSION: Failure to seek treatment for FI degrades the quality of patients’ lives over time. FI assessment tools should incorporate the quantity of fecal loss.

Measurement of anal cushions in idiopathic faecal incontinence

BACKGROUND

Faecal incontinence affects a heterogeneous population and aetiology can be multifactorial. In a subset of patients the aetiology remains idiopathic despite standard investigations. Anal cushions are important in normal continence, but have rarely been studied. The aim of this study was to measure the size of the anal cushions and to evaluate their role in patients with idiopathic faecal incontinence.

METHODS

Women in whom idiopathic faecal incontinence was diagnosed after standard anorectal investigations underwent transvaginal ultrasonography. The area of the anal cushions was measured and a cushion : canal (C : C) ratio derived, which was compared with that in a control group of women without faecal incontinence.

RESULTS

Some 21 patients with incontinence (median age 60 years) and 102 asymptomatic controls (median age 41 years) underwent scanning. The median (interquartile range) C : C ratio in the symptomatic group was significantly lower than that for controls (0.57 (0.54-0.66) versus 0.68 (0.61-0.73) respectively; P = 0.001). C : C ratio was not influenced by age (r = 0.023, P = 0.821).

CONCLUSION

The C : C ratio was reduced in patients with idiopathic faecal incontinence.

Comparison of clinical outcome between open and percutaneous lead insertion for permanent sacral nerve neurostimulation for the treatment of fecal incontinence

PURPOSE

Results from early studies on sacral nerve stimulation are based on a stimulation electrode lead that was placed under direct vision during an open surgical procedure. A percutaneous inserted lead, introduced in 2002, is now widely used. This study was designed to investigate differences in clinical efficacy and adverse complications between the two methods of lead placement.

METHODS

Prospectively collected data were analyzed for 48 patients who had undergone permanent sacral nerve stimulation for fecal incontinence at a single institution between 1997 and 2006. Eighteen patients had undergone open lead placement (Group 1) and 30 patients percutaneous lead placement (Group 2).

RESULTS

Median follow-up was 51 (range, 22-106) months for Group 1 and 8 (range, 1-40) months for Group 2 patients. There was no difference in patient demographics, severity of incontinence, or physiologic parameters between the two groups. Lead type did not affect the outcome of chronic stimulation with reductions in total episodes of incontinence being similar between the two groups (P = 0.448). No difference in infection or lead dislocation rate between the two groups was identified.

CONCLUSIONS

The percutaneously inserted lead seems to be equal to the open inserted lead in terms of clinical efficacy and complication rate in the short-term.