The effects of biofeedback training of pelvic floor muscles on fecal incontinence

Anorectal malformation and Hirschsprung's disease: a cross-sectional multicentre comparison of quality of life and bowel function to a healthy population

PURPOSE

Children with anorectal malformation (ARM) and Hirschsprung's disease (HD) often experience bowel symptoms into adulthood, despite definitive surgery. This study evaluates the quality of life (QOL) and bowel functional outcome of children treated for ARM and HD in comparison to healthy controls.

METHODS

Between December 2020 and February 2023, we recruited patients with ARM and HD aged 3-17 years at four tertiary referral centres, who had primary corrective surgery done >12 months prior. Healthy controls were age-matched and sex-matched. All participants completed the Pediatric Quality of Life Inventory Generic Core Scales 4.0, General Well-Being (GWB) Scale 3.0 and Family Impact (FI) Module 2.0 Questionnaires. Bowel Function Score (BFS) Questionnaires were also administered. We also performed subgroup analysis according to age categories. Appropriate statistical analysis was performed with p<0.05 significance. Ethical approval was obtained.

RESULTS

There were 306 participants: 101 ARM, 87 HD, 118 controls. Patients with ARM and HD had significantly worse Core and FI Scores compared with controls overall and in all age categories. In the GWB Scale, only ARM and HD adolescents (13-17 years) had worse scores than controls. ARM and HD had significantly worse BFSs compared with controls overall and in all age categories. There was significant positive correlation between BFS and Core Scores, GWB Scores and FI Scores.

CONCLUSION

Patients with ARM and HD had worse QOL than controls. Lower GWB Scores in adolescents suggests targeted interventions are necessary. Bowel function influences QOL, indicating the need for continuous support into adulthood.

Management of post-surgical faecal incontinence due to anorectal malformations by pelvic floor rehabilitation

AIM

Many patients with anorectal malformations (ARM) experience a long-lasting problem with faecal incontinence (FI). We assessed the effectiveness of a pelvic floor rehabilitation program including transcutaneous functional electrical stimulation (TFES) in combination with pelvic floor muscle (PFM) exercises on post-surgical FI in children with ARM.

METHODS

Data of 40 children at the age of 4 years or older who had undergone surgical correction for ARM and suffered from persistent FI referring for pelvic floor rehabilitation were analysed respectively. Patients underwent TFES and PFM exercises for 20 sessions. TFES was applied for 20-min during each session, two times a week. A paediatric FI score questionnaire and a bowel habit diary were completed both before and after the treatment for all children. We completed a FI quality of life questionnaire before the therapy and again after treatment for all patients.

RESULTS

Twenty-two out of 40 (55%) patients responded completely to the treatment (100% reduction in FI episodes) after the completion of treatment sessions, sustained in 19/40 (47.5%) patients after 6 months. Mean ± SD of FI score was 4.9 ± 3.6 at baseline that significantly reduced to 2.4 ± 1.3 and 2.4 ± 1.8 after completion of treatment sessions and 6 months later, respectively (P < 0.05).

CONCLUSIONS

Our results show that TFES and PFM exercises have a considerable beneficial impact on post-surgical FI in children with ARM.

Advanced Management Protocol of Transanal Irrigation in Order to Improve the Outcome of Pediatric Patients with Fecal Incontinence

Background: Transanal irrigation (TAI) is employed for children with fecal incontinence, but it can present several problems which require a study of their outcomes among different pathologies and without a tailored work up. The aim of our study was to evaluate the effectiveness of an advanced protocol in order to tailor TAI, prevent complications, and evaluate outcomes. Methods: We included 70 patients (14 anorectal malformation, 12 Hirschsprung’s disease, 24 neurological impairment, 20 functional incontinence) submitted to a comprehensive protocol with Peristeen^®: fecal score, volumetric enema, rectal ultrasound, anorectal 3D manometry, and diary for testing and parameter adjustment. Results: Among the patients, 62.9% needed adaptations to the parameters, mainly volume of irrigated water and number of puffs of balloon. These adaptations were positively correlated with pre-treatment manometric and enema data. In each group, the improvement of score was statistically significant in all cases (p 0.000); the main factor influencing the efficacy was the rate of sphincter anomalies. The ARM group had slower improvement than other groups, whereas functional patients had the best response. Conclusions: Our results showed that TAI should not be standardized for all patients, because each one has different peculiarities; evaluation of patients before TAI with rectal ultrasound, enema, and manometry allowed us to tailor the treatment, highlighting different outcomes among various pathologies, thus improving the efficacy.

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.

Pelvic floor rehabilitation for defecation disorders

Pelvic floor rehabilitation is frequently recommended for defecation disorders, in both constipation and fecal incontinence. However, the lack of patient selection, together with the variety of rehabilitation methods and protocols, often jeopardize the results of this approach, causing difficulty in evaluating outcomes and addressing proper management, and above all, in obtaining scientific evidence for the efficacy of these methods for specific indications. The authors represent different gastroenterological and surgical scientific societies in Italy, and their aim was to identify the indications and agree on treatment protocols for pelvic floor rehabilitation of patients with defecation disorders. This was achieved by means of a modified Delphi method, utilizing a working team (10 members) which developed the statements and a consensus group (15 members, different from the previous ones) which voted twice also suggesting modifications of the statements.

Understanding of Constipation Symptoms and the Diagnosis and Management of Constipation in Chinese Physicians

Background and Aims

Although a range of guidelines for the diagnosis and treatment of chronic constipation has been carried out, there was very little information about the understanding on constipation. The aim of the present study was to estimate the understanding of constipation symptoms and the diagnosis and management of constipation by clinical physicians in China.

Methods

Participants were physicians and researchers in the field of gastroenterology in China who were scheduled to attend the National Conference on gastrointestinal motility(Constipation). Based on the recommendation of the Rome Foundation Board, the self-reported questionnaire was constructed.

Findings

Although most of the opinions on symptoms of constipation were consistent, there were still some differences. Opinions on the Bristol stool form during constipation were discordant, 34% of the doctors thought that it was type 1 and type 2, while 46%of the doctors suggested that type 3 should also be considered constipation. There was no significant difference between them(P = 0.05); We investigated the interpretation on the duration of defecation prolonged, 27% of the doctors suggested it should be longer than 10 minutes, 22% of the doctors suggested it should be longer than 20 minutes, and other 22% of the doctors suggested it should be time of defecation became longer compared to previously bowel habits, there was no significant difference among them(P = 0.38).Only 36% of the doctors thought that psychotherapy was most important in the treatment of severe constipation, while 37% of the doctors thought that medication treatment was most important in the treatment of severe constipation, there was no significant difference between them(P = 0.895).

Conclusion

We were able to obtain valuable information about current views on symptoms of constipation and the diagnosis and treatment of constipation among Chinese doctors. Although most of the opinions were consistent there were still some differences. This study indicated that in practice in China there was a need for further study on the role of constipation symptoms and there may also be a need for better establishment of consensus guidelines for constipation.

Prognostic evaluation of biofeedback response in patients treated for anorectal malformation

PURPOSE

Functional bowel outcome in patients with anorectal malformation often is poor. For fecal incontinence resulting from sphincter dysfunction, biofeedback (BFB) training appears to be effective. The aim of study was to investigate the bowel function in incontinent children treated for ARM, using a clinical score, a manometric and pelvic magnetic resonance evaluation, in order to establish predictive parameters of response after BFB.

METHODS

25 children (median age of 6.5 years) with true fecal incontinence were evaluated by clinical score, anorectal manometry and magnetic resonance imaging (MRI). According to these evaluations patients were divided in 4 groups: group 1 (favorables manometry and MRI); group 2 (favorable manometry and unfavorable MRI); group 3 (unfavorable manometry and favorable MRI); group 4 (unfavorables manometry and MRI). All groups started a cycle of BFB and six months after end of BFB, were reevaluated by clinical score and manometry.

RESULTS

The overall response to BFB was excellent in 44%, discrete in 40% and poor in 16%; a better response was found in groups 1 and 2 than groups 3 and 4. The differences between groups before BFB proportionally correlated with values after BFB; a correlation with genitourinary and spinal anomalies was found.

CONCLUSIONS

Our results showed that BFB is an effective for fecal incontinence when the assessment pretreatment (functional and morphologic) is favorable; the manometry can evaluate the potential sphincterial recovery after BFB with a further prognostic benefit if correlated to morphologic evaluation with MRI.

Establishment of a new anal sphincter injury model in rats based on cardiotoxin

BACKGROUND/PURPOSE

Mainstream models for anal sphincter injury use large animals. We developed a simple and stable anal sphincter injury model in a small animal (i.e., rats) to obtain manometry measurements by using a miniaturized probe and applying cardiotoxin.

METHODS

The histological structure of the anal canal was evaluated by using manometry in normal rats (n=40). We damaged the internal and external anal sphincters by locally administering snake poison (cardiotoxin; 20 uM, 100μL 8 points). We evaluated the anal canal function through manometry measurements (n=5) and examined the histology using hematoxylin-eosin staining (at each time point, n=3; total n=15).

RESULTS

The manometry parameters and structure of the anal canal of normal rats were similar to those of humans, because rats have resting pressure, rectoanal reflex in the manometry, and an external and internal anal sphincter. After inducing injury, the following findings were observed: rhythmic wave loss and a remarkable reduction in the anal sphincter resting pressure; and local bleeding and advanced infiltration of the inflammatory cells (day 1) and the loss of muscle fibers (day 3).

CONCLUSION

This new rat model will contribute to increasing the knowledge on the anal canal.

Review of organic causes of fecal incontinence in children: evaluation and treatment

Even though fecal incontinence (FI) in children is most commonly the result of functional constipation, there are organic conditions that can be associated with incontinence. FI has a major impact on the quality of life of those children who experience it. The general objectives of any bowel program are to achieve predictability and independence. This is achieved by manipulating colonic transit and stool consistency and by producing more controlled evacuations, usually with the use of rectal interventions. Dietary interventions and medications can be used to change stool consistency or to manipulate transit by accelerating or slowing it down. Biofeedback or other interventions that increase sphincter pressure can also be used to improve anorectal function. Enemas or suppositories can be used to empty the sigmoid colon in a more controlled manner. With the recent advent of the antegrade colonic enemas, the patient can have predictable bowel movements and become independent.

Partial longitudinal resection of the anorectum and sphincter for very low rectal adenocarcinoma: a surgical approach to avoid permanent colostomy

AIM

Abdominoperineal resection has been the standard procedure for low rectal cancer. The present study details a new technique, partial longitudinal resection of the anorectum and sphincter, and assesses the oncological and functional outcomes.

METHOD

Between January 2004 and April 2008, 12 patients underwent partial longitudinal resection of the anorectum and sphincter for low rectal cancer. All patients underwent a diverting ileostomy and received biofeedback training before stoma closure. Functional results were assessed by vector manometry, Wexner constipation score and Wexner incontinence score. The quality of life (QoL) was assessed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30).

RESULTS

There was no postoperative mortality and a R0 curative resection was confirmed in every case. Morbidity included anastomotic leakage in three patients, one of whom underwent reoperation, and stenosis in 11, which was successfully managed with dilatation. The patient who underwent reoperation was not included in the functional analysis. The 11 successful patients received biofeedback training for 1-4 months, and underwent ileostomy closure 6-12 months after surgery. No patient had severe faecal incontinence after stoma closure. The EORTC QLQ-C30 global health status and QoL scores at 12 months after stoma closure were 50.4 ± 24.3, similar to preoperation scores of 52.3 ± 25.6 (P = 0.927), and not significantly different to scores for the healthy control population of 63.4 ± 23.5 (P = 0.539). No patients developed local recurrence during the median observation period (35.5 months). One patient had distant metastases at 24 months, and underwent resection of the left liver.

CONCLUSION

Curability and acceptable anal function can be obtained by partial longitudinal resection of the anorectum and sphincter in patients with very low rectal cancers. This technique is recommended as an alternative to abdominoperineal resection in patients with external sphincter muscle invasion or tumours located below the dentate line.