Factors impacting quality of life in women with fecal incontinence

The impact of anal incontinence: psychosocial and sexual consequences and factors associated with QoL in a Norwegian outpatient population

OBJECTIVES

Anal incontinence (AI) is a distressing condition with grave impact on many aspects of life, including quality of life (QoL), social life and sexual activities. This study explored how AI and bowel symptoms impact QoL in a Norwegian population by (1) describing the psychosocial and sexual consequences of AI, and (2) investigating factors most often associated with AI-specific QoL.

MATERIALS AND METHODS

A cross-sectional study among patients with AI referred to hospital outpatient clinics was conducted. A Norwegian version of ICIQ-B was used to measure bowel control, bowel symptoms, sexual impact, and impact on QoL.

RESULTS

A total of 208 persons with AI completed the questionnaire. The results demonstrated that these patients are overall embarrassed, make plans according to the bowels, ensure the presence of a nearby toilet, and many abstain from sexual activities. After adjusting for other variables included in a multivariable model, we found that having bowel accidents on one's mind had the greatest relative impact on QoL, followed by lower bowel control, using more medications to stop bowels, having more pain/soreness around the back passage, lower age, and more straining to open the bowels.

CONCLUSIONS

AI has substantial consequences for the psychosocial function and sexual activities of persons with AI. This study indicates that worrying about potential faecal accidents and the social stigma associated with this have greater impact on QoL than actual bowel leakages. Future studies should therefore focus on the emotional burden, patient coping, and health education related to bowel function and AI.

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 ).

Defecation symptoms in primary health care patients with irritable bowel syndrome

BACKGROUND

The objectives of the present study were to (a) measure the prevalence of defecation symptoms in IBS, (b) investigate the relationship between stool consistency and defecation symptoms in IBS, and (c) investigate the association of defecation symptoms with health-related quality of life (HRQL) and self-reported stress in patients with IBS cared for in a primary health care setting.

METHODS

Ten primary health care centres joined the study. 282 patients with IBS as well as 372 non-IBS controls filled in gastrointestinal symptom diaries prospectively for two weeks as well as the Perceived Stress Scale-14 (PSS14) and the EuroQol barometer to measure perceived stress and HRQL, respectively.

RESULTS

Incomplete evacuation was present in 51% vs. 21% of the stools among the IBS patients and the non-IBS controls, respectively. The need to strain during defecation was existing in 41% vs. 33% of the stools for the IBS patients and the non-IBS controls, respectively. Urgency was experienced in 37% of the stools in the IBS patients compared with 18% of the stools in the non-IBS controls. Patients with IBS experienced in a significant higher degree of overlapping symptoms per stool (p < 0.001 to p = 0.007). The occurrence of all defecation symptoms in the same patient was related to decreased HRQL, and increased stress (p = 0.001 to p < 0.001).

CONCLUSIONS

An overlap between IBS and symptoms from the anorectal region related to defecation was found in a primary health care population. Defecation symptoms are very common in primary care IBS-patients, it co-occurs with increased self-perceived stress, and decreased HRQL.

Differences in Anorectal Manometry Values Among Women With Fecal Incontinence in a Racially, Ethnically, and Socioeconomically Diverse Population

IMPORTANCE

Anorectal manometry (ARM) is a valuable diagnostic and therapeutic tool that can both aid in identifying mechanisms contributing to fecal incontinence (FI) and inform management strategies. Consensus on standard reference range values has not been established, and women of varying racial and ethnic backgrounds are not well-represented in the current literature.

OBJECTIVE

We aimed to compare ARM values between women of different racial and ethnic groups with FI.

STUDY DESIGN

We conducted a retrospective cross-sectional study of women with FI who underwent ARM at a tertiary health system in an urban underserved community between 2016 and 2021. Demographic information and ARM values were collected from the medical record. Socioeconomic status (SES) was represented by the percent of the population living below the poverty line according to zip code using U.S. census data. Anorectal manometry values were compared between racial and ethnic groups, and multivariable logistic regression was conducted to control for patient characteristics.

RESULTS

Fifty-eight women were included in the analysis: 33% Hispanic, 22% Black, and 45% White. Hispanic and Black women had higher body mass index and higher rates of diabetes and loose stools and were of significantly lower SES compared with White women. Black and Hispanic women had significantly lower thresholds for volume at first sensation and higher mean anal squeeze pressure. Differences were maintained after controlling for body mass index, diabetes, SES, and diarrhea (P = 0.03 and P = 0.01, respectively). Other ARM values were not significantly different between groups.

CONCLUSIONS

Racial and ethnic differences in ARM values among women with FI exist. Further studies are needed to determine whether these differences have an impact on symptom severity, treatment selection and outcomes, and patient satisfaction.

Characterizing the physical function decline and disabilities present among older adults with fecal incontinence: a secondary analysis of the health, aging, and body composition study

OBJECTIVE

Unhealthy aging is associated with fecal incontinence (FI) and poor physical performance. The link between FI and physical performance in older adults is unknown. We aim to examine the longitudinal relationship between FI symptoms and physical performance among older US adults.

METHODS

We analyzed a cohort of well-functioning, adults aged 70-79 years enrolled in the prospective cohort of the Health, Aging, and Body Composition study. Fecal incontinence symptoms were assessed at baseline using a validated question. Physical performance was determined by the expanded version of the Short Physical Performance Battery (HABC PBB), which includes an assessment of usual and fast walking speed and balance measures. Objective measures of physical performance were determined at baseline and year 4. Univariate and multivariate analyses compared physical performance based on presence of FI symptoms adjusting for important demographic and clinical covariates.

RESULTS

Of the 2914 participants in the Health ABC cohort, 222 (8%) had FI symptoms and 2692 (92%) did not. Mean age and BMI were 73 years and 27 kg/m2, respectively. Older adults with FI symptoms demonstrated a clinically significant decline in total HABC PBB scores from baseline to year 4 of -0.33 (95% CI: -0.41, -0.25), a statistically significant difference compared to adults without FI symptoms (-0.26 [95% CI: -0.32, -0.20]), p = 0.04. Sub-scale components demonstrated greater deficits in narrow walk speed, p = 0.03, and non-significant trend in greater deficits in repeated chair rise pace and gait speed, p ≥ 0.05.

CONCLUSIONS

Fecal incontinence symptoms are associated with clinically important declines in physical performance in older adults.

Administration of an Anal Bulking Agent With Polyacrylate-Polyalcohol Copolymer Particles Versus Endoanal Electrical Stimulation With Biofeedback for the Management of Mild and Moderate Anal Incontinence: A Randomized Prospective Study

BACKGROUND

There are few treatment options for mild-to-moderate anal incontinence with isolated internal anal sphincter defects or anal incontinence without muscle damage. Less-invasive techniques are generally favored.

OBJECTIVE

To compare the results between the use of an anal bulking agent with polyacrylate-polyalcohol copolymer particles and endoanal electrical stimulation with biofeedback in patients with mild or moderate anal incontinence.

DESIGN

This was a prospective parallel-group, single-institution, randomized clinical trial.

SETTINGS

This study was conducted in an ambulatory setting at the Colorectal Physiology Service of the Hospital das Clinicas, Medical School, University of Sao Paulo.

PATIENTS

This study included patients who had anal incontinence for >6 months with isolated internal anal sphincter muscle damage or absence of anatomical defects in the anorectal sphincter complex.

INTERVENTIONS

Anal bulking agent and endoanal electrical stimulation with biofeedback.

MAIN OUTCOME MEASURES

The primary outcome measure was the Cleveland Clinic Florida Fecal Incontinence Score, and the secondary outcome measures included quality of life, recommended procedures, and anorectal manometry.

RESULTS

There were no significant between-group differences in mean age, sex, BMI, stool consistency, and Cleveland Clinic Florida Fecal Incontinence Score (p = 0.20) at baseline. After 12 months, the Cleveland Clinic Florida Fecal Incontinence Score was found to be significantly improved in patients treated with the bulking agent compared to those treated with electrical stimulation (mean, 6.2 vs 9.2; p = 0.002), though the anorectal manometry parameters did not change significantly. The mean anal Cleveland Clinic Florida Fecal Incontinence Score declined by 4.2 points in the bulking agent group compared to a decline of 0.8 in the electrical stimulation group (mean difference in decline: 3.4 points; 95% CI, 1.2-5.5). Quality-of life evaluation showed similar results between groups comparing baseline parameters with 12-month follow-up.

LIMITATIONS

The short follow-up period of 1 year, atypical method of biofeedback, and unmatched baseline in some of the quality-of-life scales between the 2 groups limited this study.

CONCLUSIONS

In patients with mild or moderate anal incontinence, the Cleveland Clinic Florida Fecal Incontinence Score significantly improved in the bulking agent with polyacrylate-polyalcohol copolymer group compared with the endoanal electrical stimulation with biofeedback group. See Video Abstract at http://links.lww.com/DCR/B938.

ADMINISTRACIN DE UN GEL ANAL CON PARTCULAS DE COPOLMERO DE POLIACRILATOPOLIALCOHOL VERSUS ESTIMULACIN ELCTRICA ENDOANAL CON EJERCICIOS ANALES BIOFEEDBACK PARA EL MANEJO DE LA INCONTINENCIA ANAL LEVE Y MODERADA UN ESTUDI PROSPECTIVO ALEATORIZADO

ANTECEDENTES:Hasta la fecha, existen pocas opciones de tratamiento para la incontinencia anal de leve a moderada con defectos aislados del esfínter anal interno o la incontinencia anal sin daño muscular. Por lo general, se prefieren técnicas menos invasivas.OBJETIVO:El objetivo fue comparar los resultados entre el uso de un gel intra-anal con partículas de copolímero de poliacrilato-polialcohol y la estimulación eléctrica endoanal con ejercicios anales en pacientes con incontinencia anal leve o moderada.DISEÑO:Este fue un ensayo clínico aleatorio prospectivo de grupos paralelos, de una institución, realizado en cuatro etapas: base, procedimientos, postratamiento temprano y tardío.AJUSTE:Este estudio se realizó en el ambulatorio de Fisiología Colorrectal del Servicio de Coloproctología del Hospital das Clínicas, Facultad de Medicina, Universidad de São Paulo.PACIENTES:Paciente con incontinencia anal con más de 6 meses, con daño muscular aislado del esfínter anal interno o ausencia de defectos anatómicos en el esfínter anorrectal.INTERVENCIONES:Las intervenciones incluyeron la inyección del gel intra-anal y estimulación eléctrica endoanal con ejercicios anales.PRINCIPALES MEDIDAS DE RESULTADO:Indice de incontinencia fecal (Cleveland Clinic Florida), Indice de calidad de vida, los procedimientos recomendados y la manometría anorrectal.RESULTADOS:No hubo diferencias significativas entre los grupos en cuanto a la edad media, el sexo, el índice de masa corporal, la consistencia de las heces y la puntuación de incontinencia fecal (p = 0,20) al inicio del estudio. Después de 12 meses, la puntuación de incontinencia fecal mejoró significativamente en los pacientes tratados con el el gel intra-anal (media = 6,2) en comparación con los tratados con estimulación eléctrica (media = 9,2; p = 0,002), aunque los parámetros de manometría anorrectal no mejoraron significativamente. La puntuación anal media de incontinencia fecal disminuyó 4,2 puntos en el grupo del Gel intra-anal en comparación con 0,8 en el grupo de estimulación eléctrica (diferencia media en la disminución: 3,4 puntos; IC del 95%: 1,2 a 5,5). La evaluación de la calidad de vida mostró resultados similares entre los grupos que compararon los parámetros iniciales con un seguimiento de 12 meses.LIMITACIONES:Breve período de seguimiento de un año, métodos diferentes de ejercicios anales y línea de base sin igual en algunas de las escalas de calidad de vida entre los dos grupos.CONCLUSIONES:En pacientes con incontinencia anal leve y moderada, la puntuación de incontinencia fecal mejoró significativamente en el grupo de gel intra-anal con copolímero de poliacrilato-polialcohol en comparación con la estimulación eléctrica endoanal. Consulte Video Resumen en http://links.lww.com/DCR/B938. (Traducción- Dr Leonardo Alfonso Bustamante-Lopez).

Evaluation of mobile applications for patients with fecal incontinence using a modified APPLICATIONS scoring system

INTRODUCTION AND HYPOTHESIS

Mobile applications (apps) are becoming an increasingly popular means of obtaining medical information. The aim of our study was to identify and evaluate patient-centered fecal incontinence (FI) mobile apps using a modified APPLICATIONS scoring system.

METHODS

We conducted searches in the Apple App and Google Play stores to identify FI-related mobile apps using search terms reflecting both commonly accepted medical terms as well as colloquial terms used by our patients with FI. Apps that were in English, relevant to FI, patient-centered, and medically accurate were included. Each eligible app was then independently evaluated by the three authors using a modified 17-point APPLICATIONS scoring system.

RESULTS

We identified 2785 apps upon initial search using FI search terms. Fourteen apps met eligibility criteria for scoring. Most apps were bowel movement trackers (13/14, 93%), of which only three allowed for tracking of FI episodes. Only one (7%) app contained educational information specific to FI. Ten (71%) apps were fully functional at no cost. Thirteen (93%) apps cited literature. Median APPLICATIONS score was 10 (IQR 9-11). "BristolStoolChart," "FreeToBe," and "PoopLog" each received the highest total score of 13.

CONCLUSIONS

Patient-centered mobile apps that provide FI-specific educational information or allow for FI symptom tracking are scarce. While we did discover some accurate sources of information and means of tracking bowel habits, patients are likely to encounter inaccurate or irrelevant information even when searching for FI-related apps using appropriate terminology. Future app development should include FI-specific symptom tracking and educational information from reputable sources.

Tools for fecal incontinence assessment: lessons for inflammatory bowel disease trials based on a systematic review

BACKGROUND

Fecal incontinence is a disabling condition affecting up to 20% of women.

OBJECTIVE

We investigated fecal incontinence assessment in both inflammatory bowel disease and non-inflammatory bowel disease patients to propose a diagnostic approach for inflammatory bowel disease trials.

METHODS

We searched on Pubmed, Embase and Cochrane Library for all studies on adult inflammatory bowel disease and non-inflammatory bowel disease patients reporting data on fecal incontinence assessment from January 2009 to December 2019.

RESULTS

In total, 328 studies were included; 306 studies enrolled non-inflammatory bowel disease patients and 22 studies enrolled inflammatory bowel disease patients. In non-inflammatory bowel disease trials the most used tools were the Wexner score, fecal incontinence quality of life questionnaire, Vaizey score and fecal incontinence severity index (in 187, 91, 62 and 33 studies). Anal manometry was adopted in 41.2% and endoanal ultrasonography in 34.0% of the studies. In 142 studies (46.4%) fecal incontinence evaluation was performed with a single instrument, while in 64 (20.9%) and 100 (32.7%) studies two or more instruments were used. In inflammatory bowel disease studies the Wexner score, Vaizey score and inflammatory bowel disease quality of life questionnaire were the most commonly adopted tools (in five (22.7%), five (22.7%) and four (18.2%) studies). Anal manometry and endoanal ultrasonography were performed in 45.4% and 18.2% of the studies.

CONCLUSION

Based on prior validation and experience, we propose to use the Wexner score as the first step for fecal incontinence assessment in inflammatory bowel disease trials. Anal manometry and/or endoanal ultrasonography should be taken into account in the case of positive questionnaires.

Is Fluid Intake Associated With Fecal Incontinence in Women?

OBJECTIVE

The primary aim of this study was to determine if fecal incontinence (FI) is associated with self-reported fluid intake in women seeking care for pelvic floor disorders. The secondary aim was to determine the association between bowel symptoms and fluids associated with FI.

METHODS

We conducted a retrospective cross-sectional study of women presenting for evaluation of pelvic floor disorders from 2009 to 2015. The presence of FI was defined as an affirmative response of any frequency to the question, "During the last 4 weeks, how often have you leaked or soiled yourself with stool?" Data on fluid intake and bowel symptoms were collected using the Questionnaire-based Voiding Diary and Colorectal-Anal Distress Inventory short form, respectively. The relationship between FI and quartiles of fluid intake, as well as the relationship between bowel symptoms and fluids associated with FI, was analyzed.

RESULTS

Nine hundred twenty-four women were included: 379 (41%) with and 545 (59%) without FI. There was an association between FI and increasing total carbonated fluid intake (P = 0.009) and decreasing water intake (P = 0.009). The associations between FI and carbonated fluid intake and FI and water intake remained significant after controlling for patient characteristics (P < 0.05). There was a significant association between the symptom of straining to defecate and carbonated beverage intake (P = 0.046), which remained significant after controlling for patient characteristics (P < 0.001).

CONCLUSIONS

Consumption of carbonated beverages is associated with FI in women. Intake of carbonated fluids is associated with bowel symptoms that may exacerbate FI symptoms.

Combination of laser and human adipose-derived stem cells in repair of rabbit anal sphincter injury: a new therapeutic approach

Background

Anal sphincter injury leads to fecal incontinence. Based on the regenerative capability of laser and human adipose-derived stem cells (hADSCs), this study was designed to assess the effects of co-application of these therapies on anal sphincter recovery after injury.

Design

Male rabbits were assigned to equal groups (n = 7) including control, sphincterotomy, sphincterotomy treated with laser (660 nm, 90 s, immediately after sphincterotomy, daily, 14 days), hADSCs (2 × 10⁶ hADSCs injected into injured area of the sphincter immediately after sphincterotomy), and laser + hADSCs. Ninety days after sphincterotomy, manometry and electromyography were performed, sphincter collagen content was evaluated, and Ki67, myosin heavy chain (MHC), skeletal muscle alpha-actin (ACTA1), vascular endothelial growth factor A (VEGFA), and vimentin mRNA gene expression were assessed.

Results

The laser + hADSCs group had a higher resting pressure compared with the sphincterotomy (p < 0.0001), laser (p < 0.0001), and hADSCs (p = 0.04) groups. Maximum squeeze pressure was improved in all treated animals compared with the sphincterotomized animals (p < 0.0001), without a significant difference between treatments (p > 0.05). In the laser + hADSCs group, motor unit numbers were higher than those in the laser group (p < 0.0001) but did not differ from the hADSCs group (p = 0.075). Sphincterotomy increased collagen content, but the muscle content (p = 0.36) and collagen content (p = 0.37) were not significantly different between the laser + hADSCs and control groups. Laser + hADSCs increased ACTA1 (p = 0.001) and MHC (p < 0.0001) gene expression compared with laser or hADSCs alone and was associated with increased VEGFA (p = 0.009) and Ki67 mRNA expression (p = 0.01) and decreased vimentin mRNA expression (p < 0.0001) compared with laser.

Conclusion

The combination of laser and hADSCs appears more effective than either treatment alone for promoting myogenesis, angiogenesis, and functional recovery after anal sphincterotomy.

Quality of life in 1870 patients with constipation and/or fecal incontinence: Constipation should not be underestimated

BACKGROUND

Quality of life is increasingly seen as important, but remains difficult to assess in patients with functional anorectal complaints.

OBJECTIVE

We aimed to quantify quality of life and to analyse the symptomatic descriptors associated with a poor outcome in patients with faecal incontinence (FI) and/or constipation.

METHODS

The characteristics of the patients, data from self-administered questionnaires and from physical examinations were evaluated prospectively for all cases of functional anorectal disease over a period of thirteen years. Functional anorectal disease included faecal incontinence (FI) and/or constipation. Patients with scores in the lowest quartile of the Gastrointestinal Quality of Life Index (GIQLI) were considered to have suffered severe alterations to their quality of life, and were compared with the other patients.

RESULTS

In total, 1870 patients with functional anorectal disease were included (470 with a severely altered quality of life (GIQLI < 70)). Constipation predominated (1212/1870; 65.1%) and severe FI was frequent (761/1870; 40.9%). Severely altered quality of life was significantly associated with constipation (P = 0.0001), urinary urgency and incontinence (P = 0.0001), depression (P = 0.001), diabetes (P = 0.0224), severe FI (P = 0.0001), neurological disease (P = 0.0138) and liquid stools (P = 0.0002) in multivariate analysis.

CONCLUSION

Several treatable factors are associated to an impaired quality of life in patients with functional anorectal disorders. Intervention studies are mandatory (stool consistency and frequency).

Comparison of Anorectal Manometry Testing in Left Lateral and Lithotomy Positions

OBJECTIVES

Anorectal manometry (ARM) is typically performed in left lateral position, but many practitioners are more familiar with the lithotomy position. We aimed to evaluate agreement between ARM performed in left lateral and lithotomy positions and patient preference for testing position.

METHODS

We performed a prospective comparison study of left lateral versus lithotomy position for women undergoing ARM for the evaluation of fecal incontinence. Women were randomly assigned to undergo testing in either left lateral position first followed by lithotomy position, or vice versa. Women then completed a survey assessing preference of position. We performed Bland-Altman analysis to measure the level of agreement between anorectal measurements obtained in the 2 positions.

RESULTS

Twenty-one women were enrolled (mean age, 65 ± 2.2 years). We noted an acceptable level of agreement between anal pressure values obtained in left lateral versus lithotomy positions: anal resting pressure (mean difference, 0.9 mm Hg; 95% limits of agreement, 30.2 and -28.5) and anal squeeze pressure (mean difference, 1.8 mm Hg; 95% limits of agreement, 54.3 and -50.7). The level of agreement for sensory values was outside the predetermined clinical acceptability range. Most women (17/21 [81%]) reported a "good" or "very good" experience in both positions.

CONCLUSIONS

Anorectal manometry testing in the 2 positions can be used interchangeably for anal resting and squeeze pressures, but not for anorectal sensation. This modification can be introduced into clinical practice to accommodate the preference of women and practitioners who favor lithotomy position.

Prevalence of and Factors Associated With Fecal Incontinence: Results From a Population-Based Survey

BACKGROUND & AIMS

Fecal incontinence (FI) is characterized by uncontrolled passage of solid or liquid stool. We aimed to determine the prevalence and severity of FI in a large sample of US residents.

METHODS

We recruited a representative sample of patients in October 2015 to complete the National Gastrointestinal (GI) Survey; a mobile app called MyGiHealth was used to systematically collect data on GI symptoms. FI was defined as accidental leakage of solid or liquid stool. Severity of FI was determined by responses to the National Institutes of Health FI Patient Reported Outcomes Measurement Information System questionnaire. Multivariable regression models were used to identify factors associated with FI prevalence and severity.

RESULTS

Among 71,812 individuals who completed the National GI Survey, 14.4% reported FI in the past; of these, 33.3% had FI within the past 7 days. Older age, male sex, and Hispanic ethnicity increased the likelihood of having FI within the past week. Individuals with Crohn's disease, ulcerative colitis, celiac disease, irritable bowel syndrome, or diabetes were more likely to report FI. Non-Hispanic black and Hispanic individuals and individuals with Crohn's disease, celiac disease, diabetes, human immunodeficiency virus/acquired immunodeficiency syndrome, or chronic idiopathic constipation had more severe symptoms of FI than individuals without these features.

CONCLUSIONS

In a large population-based survey, 1 in 7 people reported previous FI. FI is age-related and more prevalent among individuals with inflammatory bowel disease, celiac disease, irritable bowel syndrome, or diabetes than people without these disorders. Proactive screening for FI among these groups is warranted.

Relationship between symptoms and quality of life in fecal incontinence

BACKGROUND

Most measures of fecal incontinence (FI) severity assess the frequency of solid and liquid FI, but may incorporate other features. We compared two scales-the Fecal Incontinence Severity Score (FISS) and Fecal Incontinence Severity Index (FISI)-to determine which questionnaire and which individual questions predict FI Quality of Life (FIQOL).

METHODS

A national sample of American adults completed a health questionnaire, and 234 with monthly FI were selected. Participants completed assessments of FI severity, FIQOL, and somatization. Stepwise linear regression models evaluated whether FISS and FISI total scores, or individual items on the FISS and FISI predicted FIQOL after adjusting for gender, age, income, and somatization (Brief Symptom Inventory-18).

KEY RESULTS

Reliable responses were provided by 186. Age was 49 years, and 52% were women. The mean FISS score was 8.4 (95% confidence interval [CI] 8.0-8.9, 13 questions) and mean FISI was 29.9 (95% CI 27.4-32.4, 62 questions), indicating moderate FI severity. The mean FIQOL was 2.6 (95% CI 2.4-2.7, 5 questions). Lower income, greater somatization, and total FISS and FISI scores explained 69% of FIQOL; and total FISS and FISI scores were independent predictors. On the FISS, frequency, amount, and urgency to defecate were independently associated with FIQOL. After adding somatization, all but amount remained significant. For the FISI scale, solid and liquid FI and gas were significant predictors, but adjusting for somatization excluded solid FI.

CONCLUSIONS AND INFERENCES

Five variables independently explained FIQOL: overall frequency of FI, frequency of liquid and gas leakage, urgency, and somatization.

Robotic Placement of the FENIX Continence Restoration System in a Patient with Previous Radiation to the Pelvis: A Case Report

Fecal incontinence (FI) is a disabling problem affecting women. Conservative treatment includes dietary modification, antimotility agents, and pelvic floor physical therapy. If conservative medical management is unsuccessful, surgical intervention may be required. Surgical options include rectal sphincteroplasty, bulking agent injection, radiofrequency anal sphincter remodeling, and sacral nerve stimulation therapy. Recently, a new therapy for FI, the FENIX Continence Restoration System (Torax Medical, Inc., Shoreview, MN), has become available. The FENIX device is placed through a perineal incision; however, pelvic radiation and previous anal carcinoma are both contraindications. We report the case of a 62-year-old woman with FI after anal carcinoma. Treatment included surgery, chemotherapy, and pelvic radiation. Initially, she was treated with conservative therapy and sacral nerve stimulation, which were only partially effective. A physical examination showed perineal skin changes consistent with previous radiation, which increased the patient's risk of infection and a nonhealing wound. Therefore, a robotic approach was used to place the FENIX device and improve the patient's quality of life. Our case sets a precedent for expanding the treatment options of FI in patients with previous pelvic radiation and using a robotic approach for the placement of the FENIX device.

Clinical anatomy of fecal incontinence in women

Fecal incontinence is a devastating condition that has a severe impact on quality of life. This condition disproportionately affects women and its incidence is increasing with the aging United States population. Fecal continence is maintained by coordination of a functioning anal sphincter complex, intact sensation of the anorectum, rectal compliance, and the ability to consciously control defecation. Particularly important are the puborectalis sling of the levator ani muscle complex and intact innervation of the central and peripheral nervous systems. An understanding of the intricate anatomy required to maintain continence and regulate defecation will help clinicians to provide appropriate medical and surgical management and diminish the negative impact of fecal incontinence. In this article, we describe the anatomic and neural basis of fecal continence and normal defecation as well as changes that occur with fecal incontinence in women. Clin. Anat. 30:901-911, 2017. © 2017 Wiley Periodicals, Inc.

Management of fecal incontinence - focus on a vaginal insert for bowel control

Fecal incontinence, also referred to as accidental bowel leakage, is a debilitating condition that impacts quality of life in a significant number of women. Current treatments for fecal incontinence include behavioral modification, biofeedback, drug therapy, and invasive surgical procedures. However, these treatments have suboptimal efficacy due to patient adherence, variability of presentation across patients, cost, and additional health risks. A vaginal bowel control system (Eclipse™ System) was developed to offer a low-risk, effective, and patient-managed approach to treating accidental bowel leakage. The vaginal bowel control system consists of a vaginal insert and user-controlled, pressure-regulated pump. Once inflated, the balloon of the vaginal insert is directed posteriorly to occlude the rectum, allowing the woman to immediately regain control of bowel function. This article will introduce the design evolution and feasibility studies of the Eclipse System. In addition, this review will discuss the results from a recent clinical trial that demonstrated the safety and efficacy of the vaginal bowel control system in managing fecal incontinence and other symptoms of bowel dysfunction.

Impact of a Novel Vaginal Bowel Control System on Bowel Function

BACKGROUND

Bowel dysfunction, including frequency, fecal urgency, stool consistency, and evacuation symptoms, contributes to fecal incontinence.

OBJECTIVE

The purpose of this study was to examine the impact of a vaginal bowel control system on parameters of bowel function, including frequency, urgency, stool consistency, and evacuation.

DESIGN

This was a secondary analysis of a multicenter, prospective clinical trial.

SETTINGS

This study was conducted at 6 sites in the United States, including university hospitals and private practices in urogynecology and colorectal surgery.

PATIENTS

A total of 56 evaluable female subjects aged 19 to 75 years with 4 or more fecal incontinence episodes on a 2-week bowel diary were included.

INTERVENTIONS

The study intervention was composed of the vaginal bowel control system, consisting of a vaginal insert and pressure-regulated pump.

MAIN OUTCOME MEASURES

Subjects completed a 2-week baseline diary of bowel function before and after treatment completed at 1 month. Fecal urgency, consistency of stool (Bristol score), and completeness of evacuation were recorded for all bowel movements.

RESULTS

Use of the insert was associated with an improvement in bowel function across all 4 categories. Two thirds (8/12) of subjects with a high frequency of daily stools (more than 2 per day) shifted to a normal or low frequency of stools. Analysis of Bristol stool scale scores demonstrated a significant reduction in the proportion of all bowel movements reported as liquid (Bristol 6 or 7), from 36% to 21% (p = 0.0001). On average, 54% of stools were associated with urgency at baseline compared with 26% at 1 month (p < 0.0001). Incomplete evacuations with all bowel movements were reduced from 39% to 26% of subjects at 1 month (p = 0.0034).

LIMITATIONS

The study follow-up period was 1 month (with an optional additional 2 months).

CONCLUSIONS

The vaginal bowel control system was associated with an improvement in bowel symptoms and function, including reduced bowel movement frequency, less fecal urgency, increased solid consistency, and improved evacuation in patients with significant fecal incontinence.

Impact of fecal incontinence and its treatment on quality of life in women

Fecal incontinence (FI) is a physically and psychosocially debilitating disorder which negatively impacts quality of life (QOL). It bears a significant burden not only on patients but also on their families, caretakers as well as society as a whole. Even though it is considered a somewhat common condition, especially as women age, the prevalence is often underestimated due to patients' reluctance to report symptoms or seek care. The evaluation and treatment of FI can be also hindered by lack of understanding of the current management options among healthcare providers and how they impact on QOL. This article provides a comprehensive review on the impact of FI and its treatment on QOL in women.

[Paradoxical sphincters in the abdomen]

Nitric oxide molecules serve as neurotransmitters to relax smooth muscle tension in many parts of the body. In humans and other mammals they play an important role for correct smooth muscle function in unusual locations. We previously described this mechanism (Stelzner, Chirurg. doi:10.1007/s00104-014-2777-z, 2014) using the occlusive mechanism of the upper and lower esophageal sphincters as an example. Cells producing nitric oxide can be found in the gastric fundus, the anorectal continence organ, vesicourethraltract and also in the uterine cervix in the final trimester of pregnancy. In all these locations they serve as elements of anatomical sphincter structures that have a paradoxical function. These observations confirm the points made in the introduction of this article on the stretch sphincter mechanism of the lower esophageal sphincter and the treatment of gastroesophageal reflux disease by retensioning of the esophagus in the diaphragmatic hiatus. In particular, high-resolution esophageal manometry of the lower esophageal sphincter can easily detect every functional disturbance caused by gastric plication and such changes were to be expected based on what we described in articles I and II.

Neurogenic mechanisms in bladder and bowel ageing

The prevalence of both urinary and faecal incontinence, and also chronic constipation, increases with ageing and these conditions have a major impact on the quality of life of the elderly. Management of bladder and bowel dysfunction in the elderly is currently far from ideal and also carries a significant financial burden. Understanding how these changes occur is thus a major priority in biogerontology. The functions of the bladder and terminal bowel are regulated by complex neuronal networks. In particular neurons of the spinal cord and peripheral ganglia play a key role in regulating micturition and defaecation reflexes as well as promoting continence. In this review we discuss the evidence for ageing-induced neuronal dysfunction that might predispose to neurogenic forms of incontinence in the elderly.

Factors associated with quality of life among women with fecal incontinence

INTRODUCTION AND HYPOTHESIS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Quality of life impact in women with accidental bowel leakage

BACKGROUND

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

OBJECTIVES

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

DESIGN, SETTING AND PARTICIPANTS

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

MAIN OUTCOME MEASURE

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

RESULTS

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

CONCLUSIONS

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

Fecal incontinence decreases sexual quality of life, but does not prevent sexual activity in women

BACKGROUND

The impact of anal incontinence on women's sexual function is poorly understood.

OBJECTIVE

The aim of this study was to investigate the relationship between anal incontinence and sexual activity and functioning in women.

DESIGN

This is a cross-sectional study.

SETTINGS

This investigation was conducted in a community-based integrated health care delivery system.

PATIENTS

Included were 2269 ethnically diverse women aged 40 to 80 years.

MAIN OUTCOME MEASURES

Self-administered questionnaires assessed accidental leakage of gas (flatal incontinence) and fluid/mucus/stool (fecal incontinence) in the past 3 months. Additional questionnaires assessed sexual activity, desire and satisfaction, as well as specific sexual problems (difficulty with arousal, lubrication, orgasm, or pain). Multivariable logistic regression models compared sexual function in women with 1) isolated flatal incontinence, 2) fecal incontinence (with or without flatal incontinence), and 3) no fecal/flatal incontinence, controlling for potential confounders.

RESULTS

Twenty-four percent of women reported fecal incontinence and 43% reported isolated flatal incontinence in the previous 3 months. The majority were sexually active (62% of women without fecal/flatal incontinence, 66% with isolated flatal incontinence, and 60% with fecal incontinence; p = 0.06). In comparison with women without fecal/flatal incontinence, women with fecal incontinence were more likely to report low sexual desire (OR: 1.41 (CI: 1.10-1.82)), low sexual satisfaction (OR: 1.56 (CI: 1.14-2.12)), and limitation of sexual activity by physical health (OR: 1.65 (CI: 1.19-2.28)) after adjustment for confounders. Among sexually active women, women with fecal incontinence were more likely than women without fecal/flatal incontinence to report difficulties with lubrication (OR: 2.66 (CI: 1.76-4.00)), pain (OR: 2.44 (CI: 1.52-3.91)), and orgasm (OR: 1.68 (CI: 1.12-2.51)). Women with isolated flatal incontinence reported sexual functioning similar to women without fecal/flatal incontinence.

LIMITATIONS

The cross-sectional design prevented evaluation of causality.

CONCLUSIONS

Although most women with fecal incontinence are at high risk for several aspects of sexual dysfunction, the presence of fecal incontinence does not prevent women from engaging in sexual activity. This indicates that sexual function is important to women with anal incontinence and should be prioritized during therapeutic management.

Bowel habits and fecal incontinence in patients with obesity undergoing evaluation for weight loss: the importance of stool consistency

BACKGROUND

Fecal incontinence is highly prevalent in the general population and especially in risk groups. Obesity is also common and is associated with comorbidities that impair general health and interfere with daily activities. Identifying mutable factors for fecal incontinence, such as stool consistency, is of paramount importance to improve quality of life.

OBJECTIVE

The aim of this study was to estimate the prevalence of fecal incontinence in patients with obesity undergoing evaluation for weight loss, its relationship with bowel habits, and its impact on quality of life.

DESIGN

This investigation is a cross-sectional observational study.

SETTINGS

This study was conducted in patients with obesity who were undergoing evaluation for weight loss.

MAIN OUTCOME MEASURES

Fecal incontinence was defined as loss of flatus or liquid/solid stool occurring at least monthly. Data on comorbidities, BMI, quality of life, bowel habits including stool consistency measured with the Bristol Stool Form Scale, and symptoms of fecal incontinence were collected.

RESULTS

Fifty-two patients were included, with a mean BMI of 39.6 kg/m2. Symptoms of fecal incontinence were found in 17 patients (32.7%): flatus in 9 of 17 (52.9%), liquid stool in 6 of 17 (35.2%), and solid stool in 2 of 17 (11.7%). No differences were found between patients with and without fecal incontinence in age, sex, comorbidities, or BMI. Health-related quality of life was lower in patients with fecal incontinence than in those without, but this difference was not significant, with the exception of the dimensions of role-physical (p = 0.03) and social functioning (p = 0.04). Patients with incontinence reported significantly higher percentages of altered bowel habits with nonformed stools (p = 0.004).

LIMITATIONS

The cross-sectional design hampered identification of the time at which the impact of obesity occurred.

CONCLUSIONS

Fecal incontinence is common in patients with obesity. Stool consistency was significantly different in these patients. This study supports the possibility of improving incontinence during weight loss by modifying stool consistency.