Anal sphincter repair for fecal incontinence: effect on symptom severity, quality of life, and anal sphincter squeeze pressures

Gut-Directed Pelvic Floor Behavioral Treatment for Fecal Incontinence and Constipation in Patients with Inflammatory Bowel Disease

BACKGROUND

Patients with inflammatory bowel disease (IBD) often experience functional bowel symptoms despite achieving disease remission. Although behavioral treatment (bowel and pelvic floor muscle retraining) is effective for managing constipation or fecal incontinence in non-IBD patients, there is limited evidence for its efficacy in patients with quiescent inflammatory bowel disease. The aim of this study was to evaluate the outcome of gut-directed behavioral treatment, including pelvic floor muscle training, for symptoms of constipation or fecal incontinence in patients with IBD in disease remission.

METHODS

The outcome of consecutive patients with IBD in remission and symptoms of constipation or fecal incontinence was evaluated. Patients referred to a multidisciplinary gastroenterology clinic underwent gut-directed behavioral treatment, including pelvic floor muscle training. The primary outcome was patient-reported rating of change in symptoms on a 7-point Likert scale at the completion of treatment.

RESULTS

Forty IBD patients (median age, 35 years; 80% female; 24 Crohn's disease [CD], 12 ulcerative colitis [UC], 4 UC with ileoanal pouch) with ongoing symptoms of constipation (55%) or fecal incontinence (45%), despite drug therapy, were included. The median symptom duration at referral was 2 years. Thirty-five (87%) completed treatment with a median of 2 sessions. Improvement of "6 = much better" or "7 = very much better" was reported by 77% (17/22) with fecal incontinence and 83% (15/18) with constipation. Improvement occurred irrespective of IBD diagnosis, previous perianal fistulae, colorectal surgery, presence of an ileoanal pouch, or past obstetric trauma.

CONCLUSIONS

Behavioral treatment effectively improves functional gut symptoms in a large majority of patients who are in IBD disease remission and who have not responded to drug therapy. 10.1093/ibd/izy344_video1 izy344.video1 5968879349001.

[A study on the classification of intestinal contents based on miniature reflection ultrasound]

The present artificial anal sphincter fails to distinguish the different states of intestinal contents. In this study, we tried to distinguish the intestinal content by using a reflection type ultrasonic system, so as to lay the foundation for the development of artificial anal sphincter with sensing function. We measured the numbers of reflected waves when there were solid, liquid, gaseous or no contents in the recta of 30 Bama Miniature pigs. The results showed significant difference among the numbers of reflected waves of the 4 conditions ( F = 1 088, P < 0.05). Our research suggested the reflection-type ultrasonic system could be utilized to distinguish various contents inside the intestinal lumen, thus it might offer a new effective method for the development of artificial anal sphincter with sensing function.

Impact of Pelvic Floor Physical Therapy on Quality of Life and Function After Obstetric Anal Sphincter Injury: A Randomized Controlled Trial

OBJECTIVES

There is no standard of care for women sustaining an obstetric anal sphincter injury (OASIS). We sought to determine whether pelvic floor physical therapy (PFPT) would improve the quality of life and function in women 12 weeks after OASIS.

METHODS

This institutional review board-approved randomized trial enrolled primiparous women 2 weeks after delivery complicated by OASIS. After informed consent, all subjects underwent vaginal electromyography and anorectal manometry and completed validated questionnaires; measures were repeated for all subjects at 12 weeks after delivery. The intervention arm completed 4 PFPT sessions. The primary outcome was a change in the Fecal Incontinence Quality of Life.

RESULTS

Three hundred four women were screened; 250 were excluded, and 54 were randomized. After four were lost to follow-up, analysis included 27 in the intervention arm and 23 in the control arm. Overall, mean age was 29.8 ± 4.7 years, and there were no demographic differences between groups.Fecal Incontinence Quality of Life domain scores showed improvement for both groups from baseline to 12 weeks for coping (P = 0.006) and depression (P = 0.009); however, there was no difference in domain scores between groups. For the secondary outcome of anorectal manometry, squeezing pressure improved for all subjects (P = 0.035) from baseline to 12 weeks. Vaginal EMG strength (microvolts) increased for all subjects in measures of rest average (P < 0.000), rapid peak (P = 0.006), and work average (P < 0.000), with no difference based on therapeutic arm.

CONCLUSIONS

All women showed improvements in quality of life and function at 12 weeks after delivery, regardless of treatment allocation. Further study is needed to determine whether PFPT provides a significant benefit to women having OASIS.

Evidence-Based Update on Treatments of Fecal Incontinence in Women

Fecal incontinence is a highly prevalent and distressing condition that has a negative impact on quality of life. The etiology is often multifactorial, and the evaluation and treatment of this condition can be hindered by a lack of understanding of the mechanisms and currently available treatment options. This article reviews the evidence-based update for the management of fecal incontinence.

The Differential Impact of Flatal Incontinence in Women With Anal Versus Fecal Incontinence

OBJECTIVE

The differential impact on quality of life (QOL) that leakage of both stool and flatus confers on women compared with stool only is unclear. Our aim was to characterize differences in symptom distress, impact on QOL, and anorectal testing among women with leakage of stool and flatus, stool only, and flatus only.

METHODS

A retrospective review was conducted of women undergoing evaluation of at least monthly bowel incontinence symptoms. Subjects were divided into the following 3 groups: liquid/solid stool and flatus (anal incontinence [AI]), liquid/solid stool only (fecal incontinence [FI]), and flatal only (FL). Baseline assessment included the Modified Manchester Health Questionnaire (MMHQ) including the Fecal Incontinence Severity Index (FISI), Short Form-12 (SF-12), as well as anorectal manometry and endoanal ultrasound evaluations.

RESULTS

Of 436 subjects, 381 had AI, 45 FI, and 10 FL. Significant between-group differences were noted in MMHQ (P = 0.0002) and FISI total scores (P < 0.0001) where women with AI reflected greater negative impact than women with FI. The Short Form-12 (mental and physical component summary scores) scores were similar in all 3 groups (P = 0.22, 0.08). Resting/squeeze pressures were significantly lower in AI and FI groups compared with FL (P = 0.0004), whereas rectal capacity was similar in all 3 groups. Although exploratory, MMHQ scores were similar between FI and FL groups, although FISI scores were higher in the FI group (P < 0.0001).

CONCLUSIONS

Women with AI have higher symptom specific distress and greater negative impact on QOL compared with women with FI. Treatment of all bowel incontinence symptoms is important to improve symptom-specific and general QOL.

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.

Long-term outcome after overlapping anterior anal sphincter repair for fecal incontinence

PURPOSE

The aim was to assess long-term results and quality of life following anterior anal sphincter repair for anal incontinence.

PATIENTS AND METHODS

Twenty-three female patients underwent anterior anal sphincteroplasty over a 10-year period between January 1999 and January 2009 in a gynecological surgery department. Patients were asked to complete pre- and postoperative questionnaires comprising the Jorge and Wexner incontinence score. The secondary objective was to assess pre- and post-sphincteroplasty symptom severity and sexual quality of life. Mean follow-up was 87 months (median, 91.5 months). Kaplan-Meier time-to-event analysis was applied.

RESULTS

Mean age was 52 years (±15.2), and mean postoperative Jorge and Wexner score, 7.5/20 (±4.1). Seventeen patients (85 %) declared themselves satisfied by the repair; 12 (60 %) showed good fecal continence. Fecal incontinence had a negative impact on quality of life for 15 % and on sexuality for 50 % of patients. Kaplan-Meier analysis showed 85 % conservation of anal continence correction at 1 year, 74 % at 48 months, 67 % at 60 months, and 48 % at 84 months.

CONCLUSIONS

Overlapping anterior anal sphincter repair provided lasting improvement in fecal incontinence, with satisfactory long-term functional results. At 84 months' follow-up, 48 % of patients maintained good fecal continence, with a satisfaction rate of 85 %. Anal sphincteroplasty may be a first-line attitude in young female fecal incontinence patients with a recent sphincter defect following initially undiagnosed obstetric trauma and also restores perineal comfort.

An Evidence-Based Approach to the Evaluation, Diagnostic Assessment and Treatment of Fecal Incontinence in Women

Fecal incontinence (FI) is a debilitating disorder which negatively impacts quality of life. The etiology is often multifactorial and although most women with FI are able to be treated, many remain untreated because a significant proportion of women do not report their symptoms and seek care. The evaluation and treatment of FI can be also hindered by a lack of understanding of the mechanisms and current options. This article provides a review on the evidence-based evaluation and management for FI.

Fecal incontinence after obstetric anal sphincter injuries

OBJECTIVE

To determine obstetric variables associated with the long-term prevalence of flatal and/or fecal incontinence among women who sustained obstetric anal sphincter injuries (OASIS).

METHODS

In a retrospective study of women who gave birth between January 1974 and December 1983 at the University Women's Hospital, Tuebingen, Germany, women with OASIS (n=460) were identified on the basis of chart review. Eligible women were recruited to participate in a telephone interview regarding symptoms and their retrospective preference about elective cesarean delivery.

RESULTS

The records of 20 999 deliveries, including all modes of delivery, within the 10-year study period were reviewed, and 99 women who sustained OASIS agreed to participate. The mean follow-up was 27.5±2.4 years. Among the participants, 39.4% reported fecal or flatal incontinence. Operative vaginal delivery (forceps and/or vacuum) was significantly associated with fecal but not flatal incontinence (odds ratio, 3.27; 95% confidence interval, 1.12-9.56, P=0.026). Only 9% of women with flatal incontinence and 13% of women with fecal incontinence would have opted retrospectively for cesarean delivery.

CONCLUSION

Operative vaginal delivery was significantly associated with fecal but not flatal incontinence. No other obstetric variables tested were associated with the long-term prevalence of fecal or flatal incontinence.

Vitamin D status in women with pelvic floor disorder symptoms

INTRODUCTION AND HYPOTHESIS

Our aim was to characterize the relationship between 25-hydroxyvitamin D [25(OH)D] status with pelvic floor symptom distress and impact on quality of life.

METHODS

A retrospective chart review was performed in women with a 25(OH)D level drawn within 1 year of their gynecology/urogynecology visit. Validated questionnaires including the Colorectal-Anal Distress Inventory (CRADI)-8 and Incontinence Impact Questionnaire (IIQ-7) were used. Multivariate analyses characterized pelvic floor disorder (PFD) symptom differences among women by vitamin D status.

RESULTS

We studied 394 women. Mean ± standard deviation (SD) 25(OH)D levels were higher in women without than with PFD symptoms (35.0 ± 14.1 and 29.3 ± 11.5 ng/ml, respectively (p < 0.001)]. The prevalence of vitamin D insufficiency was 51% (136/268). CRADI-8 and IIQ-7 scores were higher among women with vitamin D insufficiency (p = 0.03 and p = 0.001, respectively). Higher IIQ-7 scores were independently associated with vitamin D insufficiency (p < 0.001).

CONCLUSIONS

Insufficient vitamin D is associated with increased colorectal symptom distress and greater impact of urinary incontinence on quality of life.