Long-term results of biofeedback treatment for faecal incontinence: a comparative study with untreated controls

Short-term clinical and manometric outcomes of percutaneous tibial nerve stimulation for faecal incontinence: a large single-centre series

BACKGROUND

Faecal incontinence (FI) is common, with a significant impact on quality of life. Percutaneous tibial nerve stimulation (PTNS) is a therapy for FI; however, its role has recently been questioned. Here we report the short-term clinical and manometric outcomes in a large tertiary centre.

METHODS

A retrospective review of a prospective PTNS database was performed, extracting patient-reported FI outcome measures including bowel diary, the St Marks's Incontinence Score (SMIS) and Manchester Health Questionnaire (MHQ). Successful treatment was > 50% improvement in symptoms, whilst a partial response was 25-50% improvement. High-resolution anorectal manometry (HRAM) results before and after PTNS were recorded.

RESULTS

Data were available from 135 patients [119 (88%) females; median age: 60 years (range: 27-82years)]. Overall, patients reported a reduction in urge FI (2.5-1) and passive FI episodes (2-1.5; p < 0.05) alongside a reduction in SMIS (16.5-14) and MHQ (517.5-460.0; p < 0.001). Some 76 (56%) patients reported success, whilst a further 20 (15%) reported a partial response. There were statistically significant reductions in rectal balloon thresholds and an increase in incremental squeeze pressure; however, these changes were independent of treatment success.

CONCLUSION

Patients report PTNS improves FI symptoms in the short term. Despite this improvement, changes in HRAM parameters were independent of this success. HRAM may be unable to measure the clinical effect of PTNS, or there remains the possibility of a placebo effect. Further work is required to define the role of PTNS in the treatment of FI.

Baiona's Consensus Statement for Fecal Incontinence. Spanish Association of Coloproctology

Faecal incontinence (FI) is a major health problem, both for individuals and for health systems. It is obvious that, for all these reasons, there is widespread concern for healing it or, at least, reducing as far as possible its numerous undesirable effects, in addition to the high costs it entails. There are different criteria for the diagnostic tests to be carried out and the same applies to the most appropriate treatment, among the numerous options that have proliferated in recent years, not always based on rigorous scientific evidence. For this reason, the Spanish Association of Coloproctology (AECP) proposed to draw up a consensus to serve as a guide for all health professionals interested in the problem, aware, however, that the therapeutic decision must be taken on an individual basis: patient characteristics/experience of the care team. For its development it was adopted the Nominal Group Technique methodology. The Levels of Evidence and Grades of Recommendation were established according to the criteria of the Oxford Centre for Evidence-Based Medicine. In addition, expert recommendations were added briefly to each of the items analysed.

Systematic review and meta-analysis of anal motor and rectal sensory dysfunction in male and female patients undergoing anorectal manometry for symptoms of faecal incontinence

AIM

Manometry is the best established technique to assess anorectal function in faecal incontinence. By systematic review, pooled prevalences of anal hypotonia/hypocontractility and rectal hypersensitivity/hyposensitivity in male and female patients were determined in controlled studies using anorectal manometry.

METHODS

Searches of MEDLINE and Embase were completed. Screening, data extraction and bias assessment were performed by two reviewers. Meta-analysis was performed based on a random effects model with heterogeneity evaluated by I² .

RESULTS

Of 2116 identified records, only 13 studies (2981 faecal incontinence patients; 1028 controls) met the inclusion criteria. Anal tone was evaluated in 10 studies and contractility in 11; rectal sensitivity in five. Only three studies had low risk of bias. Pooled prevalence of anal hypotonia was 44% (95% CI 32-56, I² = 96.35%) in women and 27% (95% CI 14-40, I² = 94.12%) in men. The pooled prevalence of anal hypocontractility was 69% (95% CI 57-81; I² = 98.17%) in women and 36% (95% CI 18-53; I² = 96.77%) in men. Pooled prevalence of rectal hypersensitivity was 10% (95% CI 4-15; I² = 80.09%) in women and 4% (95% CI 1-7; I² = 51.25%) in men, whereas hyposensitivity had a pooled prevalence of 7% (95% CI 5-9; I² = 0.00%) in women compared to 19% (95% CI 15-23; I² = 0.00%) in men.

CONCLUSIONS

The number of appropriately controlled studies of anorectal manometry is small with fewer still at low risk of bias. Results were subject to gender differences, wide confidence intervals and high heterogeneity indicating the need for international collective effort to harmonize practice and reporting to improve certainty of diagnosis.

Japanese Practice Guidelines for Fecal Incontinence Part 2-Examination and Conservative Treatment for Fecal Incontinence- English Version

Examination for fecal incontinence is performed in order to evaluate the condition of each patient. As there is no single method that perfectly assesses this condition, there are several tests that need to be conducted. These are as follows: anal manometry, recto anal sensitivity test, pudendal nerve terminal motor latency, electromyogram, anal endosonography, pelvic magnetic resonance imaging (MRI) scan, and defecography. In addition, the mental and physical stress most patients experience during all these examinations needs to be taken into consideration. Although some of these examinations mostly apply for patients with constipation, we hereby describe these tests as tools for the assessment of fecal incontinence. Conservative therapies for fecal incontinence include diet, lifestyle, and bowel habit modification, pharmacotherapy, pelvic floor muscle training, biofeedback therapy, anal insert device, trans anal irrigation, and so on. These interventions have been identified to improve the symptoms of fecal incontinence by determining the mechanisms resulting in firmer stool consistency; strengthening the pelvic floor muscles, including the external anal sphincter; normalizing the rectal sensation; or periodic emptying of the colon and rectum. Among these interventions, diet, lifestyle, and bowel habit modifications and pharmacotherapy can be performed with some degree of knowledge and experience. These two therapies, therefore, can be conducted by all physicians, including general practitioners and other physicians not specializing in fecal incontinence. However, patients with fecal incontinence who did not improve following these initial therapies should be referred to specialized institutions. Contrary to the initial therapies, specialized therapies, including pelvic floor muscle training, biofeedback therapy, anal insert device, and trans anal irrigation, should be conducted in specialized institutions as these require patient education and instructions based on expert knowledge and experience. In general, conservative therapies should be performed for fecal incontinence before surgery because its pathophysiologies are mostly attributed to benign conditions. All Japanese healthcare professionals who take care of patients with fecal incontinence are expected to understand the characteristics of each conservative therapy, so that appropriate therapies will be selected and performed. Therefore, in this chapter, the characteristics of each conservative therapy for fecal incontinence are described.

Ten-year Evaluation of a Large Retrospective Cohort Treated by Sacral Nerve Modulation for Fecal Incontinence: Results of a French Multicenter Study

OBJECTIVE

The aim of this study was to assess the effectiveness of sacral nerve modulation (SNM) in a large cohort of patients implanted for at least 10 years, quantify adverse event rates, and identify predictive factors of long-term success.

SUMMARY BACKGROUND DATA

Few studies have evaluated the long-term success of SNM.

METHODS

Data collected prospectively from patients implanted for fecal incontinence (FI) in 7 French centers between January 1998 and December 2008 were retrospectively analyzed. Patient FI severity scores were assessed before and 10 years after implantation. The main evaluation criterion was the success of SNM defined by the continuation of the treatment without additional therapies. The secondary evaluation criteria were the rate of device revisions and explantations. Preoperative predictors of success at 10 years were sought.

RESULTS

Of the 360 patients (27 males, mean age: 59 ± 12 years) implanted for FI, 162 (45%) had a favorable outcome 10 years post-implantation, 115 (31.9%) failed, and 83 (23.1%) were lost to follow-up. The favorable outcome derived from the time-to-event Kaplan-Meier curve at 10 years was 0.64 (95% CI 0.58-0.69). FI severity scores were significantly better 10 years post-implantation compared to preimplantation (7.4 ± 4.3 vs 14.0 ± 3.2; P < 0.0001). During the 10-year follow-up, 233 patients (64.7%) had a surgical revision and 94 (26.1%) were explanted. A history of surgery for FI and sex (male) were associated with an increased risk of an unfavorable outcome.

CONCLUSIONS

Long-term efficacy was maintained in approximately half of the FI patients treated by SNM at least 10 years post-implantation.

Can Baseline Electromyography Predict Response to Biofeedback for Anorectal Disorder? A Long-Term Follow-Up Study

Background

Biofeedback has been recommended for the treatment of anorectal disorders, especially constipation and fecal incontinence (FI). The objective of this study was to assess the long-term efficacy of biofeedback and evaluate baseline electromyography (EMG) as a predictor for maintenance of long-term improvement.

Methods

A retrospective chart review was performed on randomly selected patients who underwent biofeedback between the years 1990 and 2000. Clinical characteristics, including EMG values at baseline (resting and contraction) as well as EMG after exercises, were collected. Patients were contacted and were classified as “improved” if they had self-reported symptomatic improvement and “not-improved” if their symptoms were unchanged or worsened.

Results

A total of 41 subjects were included. Majority (85.4%) were female, the mean age was 48.95 ± 15.46 (range 22 - 77 years) and the median follow-up was 4 years (range 4 - 5 years). Constipation was the primary indication for biofeedback in 27/41 (65.9%), FI in 9/41 (22%) and “other” in 5/41 (12.1%). Within constipation, 55.6% reported long-term improvement as compared to 66.7% of FI and 80% of the other patients. There was borderline difference in the baseline EMG (3.11 ± 1.85 µV, improved, and 7.41 ± 11.01 µV, not improved, P = 0.06) but no significant difference in post-exercise resting (3.13 ± 3.21 µV, improved, and 4.28 ± 3.63 µV, not improved, P = 0.33) and contraction EMG between the two groups.

Conclusions

Biofeedback is an important treatment tool in anorectal disorders. Over 50% of our subjects maintained their improvement 4 - 5 years after completing biofeedback therapy. A lower resting baseline EMG showed a trend of association with improvement in the long term.

Long-term outcome of anorectal biofeedback for treatment of fecal incontinence

BACKGROUND

Long-term outcome data for anorectal biofeedback (BF) for fecal incontinence (FI) is scarce. Our aims were to describe the long-term symptom profile, quality of life, and need for surgery in FI patients following BF.

METHODS

One hundred and eight consecutive female patients with FI who completed an instrumented BF course were identified for long-term follow-up. In 61 of 89 contactable patients, outcome measures were assessed at short-term (end of BF), mid-term (9 months median), and long-term (7 years median) follow-up after treatment.

KEY RESULTS

Long-term response rate (50% or more reduction in FI episodes/wk compared to before BF and not requiring surgical intervention) was seen in 33/61 (54%) patients. Thirteen of these had complete continence. Improvement was seen at short, mid, and long-term follow-up for patients' satisfaction and control of bowel function. In contrast, fecal incontinence severity index and quality of life measures, which improved in short and mid-term, were no different from baseline by long-term follow-up. Patients classified as short-term responders were far more likely to display a long-term response compared to short-term non-responders (68% vs 18%, P < .001).

CONCLUSIONS & INFERENCES

Long-term symptom improvement was observed in more than half of FI patients at 7 year post BF follow-up. Quality of life improvements, however, were not maintained. Patients improving during the initial BF program have a high chance of long-term improvement, while patients who do not respond to BF should be considered early for other therapies.

Fecal incontinence - Challenges and solutions

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

Integrated low-intensity biofeedback therapy in fecal incontinence: evidence that "good" in-home anal sphincter exercise practice makes perfect

BACKGROUND

Biofeedback therapy (BFT) is an established treatment for fecal incontinence (FI), with access often being restricted to tertiary centers due to resources and the perceived requirement for high-intensity regimes. However, the optimal regime remains unknown. We evaluated outcomes from our low-intensity integrated BFT program in a secondary care center.

METHODS

Outcomes of our BFT service for FI were evaluated retrospectively. Response was defined by ≥50% improvement in FI frequency from baseline or complete continence. Responders were compared to non-responders for factors including symptoms, manometry data, sphincter exercise technique and duration of practice, and the number and frequency of sessions. Where patients dropped out, outcomes and the reason for dropout were obtained retrospectively.

KEY RESULTS

Fecal incontinence patients (n=205, median 62 years, 72% female) attended a median (IQR) 3 (2) BFT sessions with 55 (36) days between visits. Overall, 146/205 (71%) responded with 97/205 (47%) achieving continence. Fecal incontinence frequency improved dramatically in completed cases (P=0.000). While non-response was associated with males (P=0.03) and dropout (P=0.000), "good" anal sphincter exercise technique (P=0.008) and longer in-home practice (P=0.007) and more sessions (P=0.04) were associated with response. Dropout rate was 80/205 (39%), with the reason for dropout being obtained in 80%.

CONCLUSIONS & INFERENCES

Despite low-intensity BFT, comparable outcomes to data from tertiary centers were achieved. Our data emphasize the importance of technique and in-home practice of anal sphincter exercises. Customizing BFT intensity based on predictive factors and encouraging in-home practice may optimize outcomes, reduce dropout rates, and rationalize resources.

Biofeedback Therapy Before Ileostomy Closure in Patients Undergoing Sphincter-Saving Surgery for Rectal Cancer: A Pilot Study

Purpose

This study prospectively investigated the effects of biofeedback therapy on objective anorectal function and subjective bowel function in patients after sphincter-saving surgery for rectal cancer.

Methods

Sixteen patients who underwent an ileostomy were randomized into two groups, one receiving conservative management with the Kegel maneuver and the other receiving active biofeedback before ileostomy closure. Among them, 12 patients (mean age, 57.5 years; range, 38 to 69 years; 6 patients in each group) completed the study. Conservative management included lifestyle modifications, Kegel exercises, and medication. Patients were evaluated at baseline and at 1, 3, 6, and 12 months after ileostomy closure by using anal manometry, modified Wexner Incontinence Scores (WISs), and fecal incontinence quality of life (FI-QoL) scores.

Results

Before the ileostomy closure, the groups did not differ in baseline clinical characteristics or resting manometric parameters. After 12 months of follow-up, the biofeedback group demonstrated a statistically significant improvement in the mean maximum squeezing pressure (from 146.3 to 178.9, P = 0.002). However, no beneficial effect on the WIS was noted for biofeedback compared to conservative management alone. Overall, the FI-QoL scores were increased significantly in both groups after ileostomy closure (P = 0.006), but did not differ significantly between the two groups.

Conclusion

Although the biofeedback therapy group demonstrated a statistically significant improvement in the maximum squeezing pressure, significant improvements in the WISs and the FI-QoL scores over time were noted in both groups. The study was terminated early because no therapeutic benefit of biofeedback had been demonstrated.

Is electromyography a predictive test of patient response to biofeedback in the treatment of fecal incontinence?

AIM

Biofeedback is effective in more than 70% of patients with fecal incontinence. However, reliable predictors of successful treatment have not been identified. The aim was to identify clinical variables and diagnostic tests, particularly electromyography, that could predict a successful outcome.

METHODS

We included 135 consecutive women with fecal incontinence treated with biofeedback. Clinical evaluation, manometry, ultrasonography, electromyography, and pudendal nerve terminal motor latency were performed before therapy. Treatment outcome was assessed using a symptoms diary, Wexner incontinence score and the patient's subjective perception.

RESULTS

According to the symptoms diaries, 106 (78.5%) women had a good clinical result and 29 (21.5%) had a poor result. There were no differences in age, severity and type of fecal incontinence. Maximum resting pressure (39.3 ± 19.1 mmHg vs. 33.7 ± 20.2 mmHg; P = 0.156) and maximum squeeze pressure (91.8 ± 33.2 mmHg vs. 79.8 ± 31.2 mmHg; P = 0.127) were higher in patients having good clinical outcome although the difference was not significant. There were no differences in the presence of sphincter defects or abnormalities in electromyographic recordings. Logistic regression analysis found no independent predictive factor for good clinical outcome.

CONCLUSIONS

Biofeedback is effective in more than 75% of patients with fecal incontinence. Clinical characteristics of patients and results of baseline tests have no predictive value of response to therapy. Specifically, we found no association between severity of electromyographic deficit and clinical response.

Current management of fecal incontinence

OBJECTIVE

To review the management of fecal incontinence, which affects more than 1 in 10 people and can have a substantial negative impact on quality of life.

METHODS

The medical literature between 1980 and April 2012 was reviewed for the evaluation and management of fecal incontinence.

RESULTS

A comprehensive history and physical examination are required to help understand the severity and type of symptoms and the cause of incontinence. Treatment options range from medical therapy and minimally invasive interventions to more invasive procedures with varying degrees of morbidity. The treatment approach must be tailored to each patient. Many patients can have substantial improvement in symptoms with dietary management and biofeedback therapy. For younger patients with large sphincter defects, sphincter repair can be helpful. For patients in whom biofeedback has failed, other options include injectable medications, radiofrequency ablation, or sacral nerve stimulation. Patients with postdefecation fecal incontinence and a rectocele can benefit from rectocele repair. An artificial bowel sphincter is reserved for patients with more severe fecal incontinence.

CONCLUSION

The treatment algorithm for fecal incontinence will continue to evolve as additional data become available on newer technologies.

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.

The role of anorectal investigations in predicting the outcome of biofeedback in the treatment of faecal incontinence

OBJECTIVE

The current literature does not provide unequivocal evidence on prognostic factors of patients' response to biofeedback for management of faecal incontinence. The aim of this study was to identify independent predictors of patient response to biofeedback.

MATERIAL AND METHODS

Baseline demographic characteristics, symptomatology and anorectal investigation reports of 137 patients who completed biofeedback therapy were analysed retrospectively. Short-term response (<3 months) to biofeedback was assessed using subjective criteria (improvement/ no improvement). P Values < 0.05 were considered to be statistically significant.

RESULTS

At univariate analysis, age, duration of symptoms, severity of faecal incontinence, mean maximum squeeze and resting pressure differed significantly (p < 0.05) were associated with patients' response. However, after performing logistic regression analysis age, duration and severity of symptoms were the only variables associated with the outcome (p Values were 0.041, 0.022 and 0.025, respectively).

CONCLUSION

Three independent factors (younger age, shorter duration and lower severity of faecal incontinence) were associated with patient outcome after completing our unit's biofeedback protocol. Anorectal investigations are of questionable value in patient selection for biofeedback therapy.

Electrical stimulation and biofeedback for the treatment of fecal incontinence: a systematic review

PURPOSE

This systematic review determines the best known form of biofeedback (BF) and/or electrical stimulation (ES) for the treatment of fecal incontinence in adults and rates the quality of evidence using the Grades of Recommendation, Assessment, Development, and Evaluation. Attention is given to type, strength, and application mode of the current for ES and to safety.

METHODS

Methods followed the Cochrane Handbook. Randomized controlled trials were included. Studies were searched in The Cochrane Library, MEDLINE, and EMBASE (registration number (PROSPERO): CRD42011001334).

RESULTS

BF and/or ES were studied in 13 randomized parallel-group trials. In 12 trials, at least one therapy group received BF alone and/or in combination with ES, while ES alone was evaluated in seven trials. Three (four) trials were rated as of high (moderate) quality. Average current strength was reported in three of seven studies investigating ES; only two studies reached the therapeutic window. No trial showed superiority of control, or of BF alone or of ES alone when compared with BF + ES. Superiority of BF + ES over any monotherapy was demonstrated in several trials. Amplitude-modulated medium-frequency (AM-MF) stimulation, also termed pre-modulated interferential stimulation, combined with BF was superior to both low-frequency ES and BF alone, and 50 % of the patients were continent after 6 months of treatment. Effects increased with treatment duration. Safety reporting was bad, and there are safety issues with some forms of low-frequency ES.

CONCLUSIONS

There is sufficient evidence for the efficacy of BF plus ES combined in treating fecal incontinence. AM-MF plus BF seems to be the most effective and safe treatment.

KEY MESSAGES

• The higher the quality of the randomized trial the more likely was a significant difference between treatment groups. • Two times more patients became continent when biofeedback was used instead of a control, such as pelvic floor exercises. • Two times more patients became continent when biofeedback plus electrical stimulation was used instead of biofeedback only. • Low-frequency electrical stimulation can have adverse device effects, and this is in contrast to amplitude-modulated medium-frequency electrical stimulation. • There is high quality evidence that amplitude-modulated medium-frequency electrical stimulation plus electromyography biofeedback is the best second-line treatment for fecal incontinence.

[Functional proctology at the University of Pécs]

INTRODUCTION

Functional proctological investigations have been introduced at Pécs University of Sciences 15 years ago. The Pelvic Floor Multidisciplinary Team has been re-launched after many years of pause in 2010. Experience of the team in the treatment of faecal incontinence and obstructed defecation syndrome is discussed.

PATIENTS

In the past 3 years 9 patients underwent sphincter reconstruction for faecal incontinence. The Pelvic Floor Team in the past 1.5 year consulted 31 patients with constipation, who were considered by the referee for surgical intervention. Following investigations 10 patients underwent surgery, the rest of them were treated conservatively. Seven patients underwent perineal reconstruction with mesh, three patients had ventral rectopexy with additional levatoro-pexy.

RESULTS

78% of patients operated on for faecal incontinence reported full continence, 88% improvement. We invented a new symptom score with a maximum of 20 points to evaluate results of treatment of patients with Obstructed Defecation Syndrome. Patients who underwent perineal repair were interviewed pre and postoperatively. They scored 14 ± 2.83 and 5.4 ± 4.62 points, respectively (p = 0.0075).

CONCLUSION

Functional proctological patients require a specialist approach from history taking through investigation to treatment. Majority of patients benefit from conservative treatment. Adequate patient selection is essential for successful surgical treatment. Symptom scores applied pre and postoperatively facilitate proper patient selection for various surgical methods.

Fecal incontinence: mechanisms and management

PURPOSE OF REVIEW

Fecal incontinence is a common condition, which leads to impaired quality of life and huge financial cost at an individual and societal level. Recent studies have identified novel and potentially modifiable risk factors. Newer diagnostic modalities are giving more detailed information about underlying disorders, helping to implement targeted treatment. Many therapeutic options exist, and newer treatments are changing outcomes. This article will review recent developments in mechanisms, diagnosis, and treatment of fecal incontinence.

RECENT FINDINGS

Potentially modifiable risk factors have recently been identified, and should translate to changes in clinical practice and hopefully patient outcomes. These include diarrhea, smoking, and dietary fiber. Advances have been made in anatomical and physiological testing of the anorectum and this may assist in clarifying the diagnosis and guiding management. The long-term benefit of biofeedback has been questioned but patient selection may be key. Novel pharmacological therapies (e.g., clonidine) and minimally invasive surgical procedures are changing outcomes in well selected patients. The development of a magnetic anal sphincter may add a new management alternative in patients who are refractory to conservative management.

SUMMARY

Fecal incontinence remains a clinical challenge. Only a minority of persons with fecal incontinence seek treatment, but for those who do, improved understanding of risk factors coupled with diagnostic techniques and treatments are improving outcomes.