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Abdelrahman EM, Mohamed AG, Abdel Ghafar MA, Ahmed ME, Ali RR, Kharoub MS. Long-Term Outcome of Transcutaneous Posterior Tibial Nerve Stimulation in the Treatment of Functional Non-Retentive Fecal Incontinence in Children. Surg Innov 2024; 31:33-41. [PMID: 38084751 DOI: 10.1177/15533506231221942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2024]
Abstract
BACKGROUND Functional non-retentive fecal incontinence (FNRFI) is a psychologically upsetting and embarrassing issue and affects children's quality of life negatively. AIM OF THIS STUDY Evaluation of the short and long-term effect of Bilateral transcutaneous posterior tibial nerve stimulation (BTPTNS) in the treatment of FNRFI in children and its impact on the quality of life (QoL). Methodology: The current randomized controlled study included 94 Children with FNRFI who were randomly allocated into two equal groups. Group A received BTPTNS and Group B Received Sham BTPTNS. Follow-up was planned for 24 months for manometric findings, incontinence score, Incontinence episodes, and the QoL. RESULTS The incontinence score was significantly decreases in Group A more than what was reported in Group B at 6, 12, 24 months follow up . In group A 53.2% of the included children who received BTPTNS showed a decrease in the incontinence episodes more than 75% and among them, 23.4% were fully continent. All the QoL domains were significantly improved in Group A after 6, 12, and 24 months when compared with Group B. CONCLUSION BTPTNS can be a good modality in the treatment of FNRFI with favorable long-term maintenance of its effect together with a remarkable positive impact on all domains of QoL.
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Affiliation(s)
- Emad M Abdelrahman
- General Surgery Department, Faculty of Medicine, Benha University, Benha, Egypt
| | - Amr G Mohamed
- General Surgery Department, Faculty of Medicine, Benha University, Benha, Egypt
| | | | - Marwa Elsayed Ahmed
- Department of Pediatrics, Faculty of Medicine, Benha University, Benha, Egypt
| | - Rania R Ali
- Department of Basic Science for Physical Therapy, Faculty of Physical Therapy, Cairo University, Dokki, Egypt
| | - Mohamed S Kharoub
- General Surgery Department, Faculty of Medicine, Benha University, Benha, Egypt
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Liapis SC, Baloyiannis I, Perivoliotis K, Lytras D, Theodoropoulos G, Tzovaras G. The Role of Percutaneous Tibial Nerve Stimulation (PTNS) in Low Anterior Resection Syndrome (LARS): A Systematic Review and Meta-analysis. J Gastrointest Cancer 2023; 54:1128-1139. [PMID: 36703030 DOI: 10.1007/s12029-023-00910-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2023] [Indexed: 01/28/2023]
Abstract
PURPOSE The aim of the present study was to evaluate the pooled efficacy of percutaneous tibial nerve stimulation (PTNS) in patients with low anterior resection syndrome (LARS). MATERIAL AND METHODS This study was based on the Cochrane Handbook for Systematic Reviews of Interventions and the PRISMA guidelines. The primary endpoint was the pooled effect size of PTNS in LARS score (LARSS). Secondary endpoints included incontinence (Fecal Incontinence Score-FIC, Obstructive Defecation Syndrome-ODS), sexual functionality and quality of life (QoL) questionnaires, and manometric evaluations. Continuous outcomes were reported as weighted mean difference (WMD), with the corresponding 95% confidence interval (95% CI). Quality evaluation was performed via the National Institutes of Health (NIH) quality assessment tool. RESULTS Overall, 5 studies were included. PTNS resulted to reduced LARSS values (WMD: - 5.68, 95%CI: - 7.73, - 3.63, p < 0.001). A similar effect was noted in St Mark's FIC (p < 0.001) and ODS (p = 0.02) score. An improvement in several QoL scales was found. There was no effect in sexual functionality and manometric measurements. Compared to sham, PTNS significantly improved LARSS. CONCLUSIONS The application of PTNS in patients with LARS results in an improvement in multiple clinical parameters, including defecation functionality and quality of life. Due to several study limitations, further high quality RCTs are required to delineate the exact efficacy of PTNS.
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Affiliation(s)
| | - Ioannis Baloyiannis
- Department of Surgery, University Hospital of Larissa, Mezourlo, 41110, Larissa, Greece
| | | | - Dimitrios Lytras
- Department of Surgery, General Hospital of Volos, Polymeri 134, 38222, Volos, Greece
| | - Georgios Theodoropoulos
- Department of Surgery, National and Kapodistrian University of Athens, Hippocration General Hospital, Athens, Greece
| | - Georgios Tzovaras
- Department of Surgery, University Hospital of Larissa, Mezourlo, 41110, Larissa, Greece
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Bosch-Ramírez M, Sánchez-Guillén L, Alcaide-Quirós MJ, Aguilar-Martínez MM, Bellón-López M, López Delgado A, López-Rodríguez-Arias F, Muñoz-Duyos A, Barber-Valles X, Arroyo A. Long-term efficacy of percutaneous tibial nerve stimulation for faecal incontinence and a new approach for partial responders. Tech Coloproctol 2023; 27:443-451. [PMID: 36222850 PMCID: PMC10169891 DOI: 10.1007/s10151-022-02711-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 09/30/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND The aim of the present study was to evaluate the long-term efficacy of percutaneous tibial nerve stimulation (PTNS) for patients with faecal incontinence (FI) refractory to conservative treatment. Secondary aims were to identify predictors of response and validate new treatment pathways for partial responders. METHODS A prospective, interventional study was carried out in a specialist defecatory disorder unit from a university hospital between January 2010 and June 2017 on patients > 18 years old with FI refractory to conservative treatment. Thirty-minute PTNS sessions were performed in three phases (weekly, biweekly and monthly) up to a year, with clinical reassessment at 3, 6, 12 and 36 months. Patients were classified as optimal responders when their pretreatment Wexner score decreased > 50%; partial responders when it decreased 25-50%; and insufficient responders if it decreased < 25%. Only optimal and partial responders progressed into successive phases. RESULTS Between 2010 and 2017, 139 patients (110 women, median age 63 years [range 22-82 years]) were recruited. After the first phase, 4 patients were optimal responders, 93 were partial responders and 36 were insufficient responders. At 6 and 12 months, 66 and 89 patients respectively were optimal responders, with an optimal response rate of 64% at the end of treatment. A total of 93.3% patients with a partial response initially finally became optimal responders. Furthermore, at 36 months, 71.9% of patients were still optimal responders without supplementary treatment, although their quality of life did not improve significantly. Baseline Wexner scores ≤ 10 and symptom duration < 1 year were identified as predictive factors for positive responses to PTNS. CONCLUSIONS Patients undergoing PTNS for 1 year following this protocol had optimal long-term responses. PTNS sessions for up to 1 year in patients who were partial responders prevents a high percentage of them from needing more invasive treatments, and maintains long-term continence in patients who were optimal responders.
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Affiliation(s)
- M. Bosch-Ramírez
- Department of General Surgery, Colorectal Unit, Elche University Hospital, University Miguel Hernández of Elche, Camino de la Almazara 11, 03203 Elche, Alicante Spain
| | - L. Sánchez-Guillén
- Department of General Surgery, Colorectal Unit, Elche University Hospital, University Miguel Hernández of Elche, Camino de la Almazara 11, 03203 Elche, Alicante Spain
| | - M. J. Alcaide-Quirós
- Department of General Surgery, Colorectal Unit, Elche University Hospital, University Miguel Hernández of Elche, Camino de la Almazara 11, 03203 Elche, Alicante Spain
| | - M. M. Aguilar-Martínez
- Department of General Surgery, Colorectal Unit, Elche University Hospital, University Miguel Hernández of Elche, Camino de la Almazara 11, 03203 Elche, Alicante Spain
| | - M. Bellón-López
- Department of General Surgery, Colorectal Unit, Elche University Hospital, University Miguel Hernández of Elche, Camino de la Almazara 11, 03203 Elche, Alicante Spain
| | - A. López Delgado
- Department of General Surgery, Colorectal Unit, Elche University Hospital, University Miguel Hernández of Elche, Camino de la Almazara 11, 03203 Elche, Alicante Spain
| | - F. López-Rodríguez-Arias
- Department of General Surgery, Colorectal Unit, Elche University Hospital, University Miguel Hernández of Elche, Camino de la Almazara 11, 03203 Elche, Alicante Spain
| | - A. Muñoz-Duyos
- Department of General Surgery, Colorectal Unit, Mútua Terrassa University Hospital, University of Barcelona, Terrassa, Barcelona Spain
| | - X. Barber-Valles
- Department of General Surgery, Colorectal Unit, Elche University Hospital, University Miguel Hernández of Elche, Camino de la Almazara 11, 03203 Elche, Alicante Spain
- Center for Operations Research, University Miguel Hernández of Elche, Elche, Alicante Spain
- Joint Research Unit on Statistical Methods in Health Sciences UMH-FISABIO, University Miguel Hernández of Elche, Elche, Spain
| | - A. Arroyo
- Department of General Surgery, Colorectal Unit, Elche University Hospital, University Miguel Hernández of Elche, Camino de la Almazara 11, 03203 Elche, Alicante Spain
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Jin Q, Zhu Y, Yin P, Li X. Tibial nerve electrical stimulation for fecal incontinence: a systematic review and meta-analysis. Updates Surg 2022:10.1007/s13304-022-01444-w. [DOI: 10.1007/s13304-022-01444-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 12/11/2022] [Indexed: 12/23/2022]
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Rodríguez Carrillo R, Ruiz Carmona MD, Alós Company R, Frangi Caregnato A, Alarcón Iranzo M, Solana Bueno A, Lozoya Trujillo R, García-Granero Ximénez E. Importance of some technical aspects of the procedure of percutaneous posterior tibial nerve stimulation in patients with fecal incontinence. Cir Esp 2021; 99:585-592. [PMID: 34373228 DOI: 10.1016/j.cireng.2021.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 08/25/2020] [Indexed: 11/18/2022]
Abstract
INTRODUCTION The results of percutaneous posterior tibial nerve stimulation (PTNS) in the treatment of fecal incontinence (IF) are modest. The aim of the study is to assess the relationship of some technical aspects with the clinical response: location of the nerve, distal response (motor or sensory) and accommodation. METHODS Prospective study of patients with FI undergoing PTNS therapy. The clinical response was assessed using the Wexner scale, defecation diary and anorectal manometry. RESULTS 32 patients were studied. The intensity of localization (proximity to the nerve) was not correlated with clinical or manometric changes. Motor response was associated with a decrease on the Wexner scale [12.12 (±5.39) to 7.71 (±4.57) P < .005], the number of episodes of passive incontinence [8.78 (±9.64) to 4.11 (±7.11) P = .025], the total number of incontinence episodes [16.11 (±16.03) to 7.78 (±11.34) P = .009] and the number of days with fecal soiling [6.89 (±5.53) to 2.56 (±4.13) P = .002] and with an increase in the length of the manometric anal canal at rest [4.55 (±0.596) to 4.95 (±0.213) P = .004]. The increase in stimulation (accommodation) was inversely correlated with the decrease in the Wexner scale (r = -0.677 P < .005) and the number of days with soiling (r = -0.650 P = .022). CONCLUSIONS The motor response during PTNS seems to be related to a better clinical response. The accommodation phenomenon could be associated with worse results. The proximity of the electrode to the nerve does not seem to be important as long as a good distal response is achieved.
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Affiliation(s)
| | | | - Rafael Alós Company
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | | | - Marina Alarcón Iranzo
- Servicio de Cirugía General y del Aparato Digestivo, Hospital de Sagunto, Valencia, Spain
| | - Amparo Solana Bueno
- Servicio de Cirugía General y del Aparato Digestivo, Hospital de Sagunto, Valencia, Spain
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Biofeedback versus bilateral transcutaneous posterior tibial nerve stimulation in the treatment of functional non-retentive fecal incontinence in children: A randomized controlled trial. J Pediatr Surg 2021; 56:1349-1355. [PMID: 33092813 DOI: 10.1016/j.jpedsurg.2020.09.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/17/2020] [Accepted: 09/18/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND Biofeedback and transcutaneous posterior tibial nerve stimulation (TPTNS) can be used in treatment of Functional non-retentive fecal incontinence (FNRFI). Aim of this study was to evaluate the early effect of Biofeedback versus (TPTNS) and treatment by Kegal exercises and dietetic regulations in management of (FNRFI) in children. METHODOLOGY The current prospective randomized controlled study included 93 children with FNRFI who were randomly allocated into the 3 groups. Group A (n = 28) were treated by dietetic regulation and Kegal exercises. Group B (n = 34) received biofeedback while group C (n = 31) received (TPTNS) for 3 months. Follow up using St' Mark's incontinence score and high resolution manometry was done at 3 and 6 months and compared to the initial records. RESULTS There was statistically significant decrease in the incontinence score in Group B and C compared to Group A at 3 and 6 months (p ˂ 0.001). Resting and squeeze pressures showed significant increase group B and C (p ˂ 0.001). Patients in Group B and C showed significant decrease volume of balloon required for 1st sensation (p ˂ 0.001 and 0.034) respectively. CONCLUSION Biofeedback is more effective than TPTNS, Kegal exercises and dietetic regulations in treatment of FNRFI in children for short term follow-up. LEVEL OF EVIDENCE Level I. TYPE OF STUDY Treatment Study.
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Abstract
BACKGROUND Chronic functional constipation is a highly prevalent disorder in which, when conservative measures fail to relieve symptoms, surgical interventions are sometimes indicated. In recent years, neuromodulation for the treatment of functional constipation has gained interest but its role and effectiveness are still unclear. The purpose of this review is to provide a systematic overview on the current literature on the different modalities of neurostimulation and their effect on chronic functional constipation in adults as reported in the literature. METHODS A search in the literature for articles concerning the effect of different types of neuromodulation on constipation was performed in PubMed using extensive search terms for the different modalities of neuromodulation. Studies and trials were checked for eligibility. For all types of neuromodulation together, 27 articles were included. RESULTS 17 studies were included on SNM (sacral nerve modulation). Although multiple studies show positive results on the effect of SNM in constipation, double-blind crossover RCT's (randomised controlled trials) showed no significant effect. 3 studies were included for tSNS (transcutaneous sacral nerve stimulation), 2 for PTNS (percutaneous tibial nerve stimulation) and 2 for TTNS (transcutaneous tibial nerve stimulation). Studies and trials on these modalities of neuromodulation reported ambiguous results on statistical significance of the effect. For transcutaneous IFC (interferential current therapy) 2 studies were included, which both reported a statistically significant effect on all outcomes. CONCLUSION The beneficial effect of neuromodulation in chronic functional constipation remains questionable. However, neuro-modulation might be worth considering in patients refractory to treatment before turning to more invasive measures. Future research should shed more light on the effects of neuromodulation in constipation.
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Percutaneous electrical stimulation of the posterior tibial nerve for the treatment of fecal incontinence: manometric results after 6 months of treatment. Int J Colorectal Dis 2020; 35:2049-2054. [PMID: 32627071 DOI: 10.1007/s00384-020-03564-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/05/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Posterior tibial nerve stimulation (PTNS) is a minimally invasive approach with little adverse effects, but obtaining good results as shown in the different scales for the evaluation of the severity of incontinence. The aim of this study was to determine the effects of PTNS based on manometric determinations of the anal sphincter and severity during a period of treatment of 6 months (18 sessions). PATIENTS AND METHODS A prospective interventional study of patients with fecal incontinence was performed. Subjects underwent one 30-min session every week for 12 weeks, followed by 6 sessions every 2 weeks. The effect on incontinence was evaluated by means of St. Marks and defecatory urgency scales, and manometry. RESULTS Seventy-three patients were included. At baseline, 28.8% of the patients had a retention time of less than 1 min. At 12 weeks, 39.7% of the patients presented a retention time to 5-10 min and at 18 weeks 37% presented it over 10 min. At baseline, mean St Marks score was 15.1 + 5.1, improving after 12 weeks of treatment to 8.9 + 5 (p < 0.001). After 18 sessions, a greater improvement was observed up to 4 + 4.8 (p < 0.001). Maximum resting pressure showed a significant increase after treatment (mean increase 9.8 mmHg; p = 0.006). Similarly, maximum squeeze pressure also presented a significant augmentation (mean increase 25.3 mmHg; p = 0.002). CONCLUSION Eighteen sessions of PTNS, divided in 12 weekly sessions and 6 sessions every 2 weeks, have shown to obtain benefits, reducing the St. Marks and the defecatory urgency scores, and increasing the manometric values.
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Rodríguez Carrillo R, Ruiz Carmona MD, Alós Company R, Frangi Caregnato A, Alarcón Iranzo M, Solana Bueno A, Lozoya Trujillo R, García-Granero Ximénez E. Importance of some technical aspects of the procedure of percutaneous posterior tibial nerve stimulation in patients with fecal incontinence. Cir Esp 2020; 99:S0009-739X(20)30276-1. [PMID: 32981656 DOI: 10.1016/j.ciresp.2020.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 08/24/2020] [Accepted: 08/25/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The results of percutaneous posterior tibial nerve stimulation (PTNS) in the treatment of fecal incontinence (IF) are modest. The aim of the study is to assess the relationship of some technical aspects with the clinical response: location of the nerve, distal response (motor or sensory) and accommodation. METHODS Prospective study of patients with FI undergoing PTNS therapy. The clinical response was assessed using the Wexner scale, defecation diary and anorectal manometry. RESULTS 32 patients were studied. The intensity of localization (proximity to the nerve) was not correlated with clinical or manometric changes. Motor response was associated with a decrease on the Wexner scale [12.12 (± 5.39) to 7.71 (± 4.57) p < 0.005], the number of episodes of passive incontinence [8.78 (± 9.64) to 4.11 (± 7.11) p = 0.025], the total number of incontinence episodes [16.11 (± 16.03) to 7.78 (± 11.34) p = 0.009] and the number of days with faecal soiling [6.89 (± 5.53) to 2.56 (± 4.13) p = 0.002] and with an increase in the length of the manometric anal canal at rest [4.55 (± 0.596) to 4.95 (± 0.213) p = 0.004]. The increase in stimulation (accommodation) was inversely correlated with the decrease in the Wexner scale (r = -0.677 p < 0.005) and the number of days with soiling (r = -0.650 p = 0.022). CONCLUSIONS The motor response during PTNS seems to be related to a better clinical response. The accommodation phenomenon could be associated with worse results. The proximity of the electrode to the nerve does not seem to be important as long as a good distal response is achieved.
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Affiliation(s)
| | | | - Rafael Alós Company
- Servicio de Cirugía General y del Aparato Digestivo. Hospital Universitario y Politécnico La Fe, Valencia, España
| | | | - Marina Alarcón Iranzo
- Servicio de Cirugía General y del Aparato Digestivo. Hospital de Sagunto, Valencia, España
| | - Amparo Solana Bueno
- Servicio de Cirugía General y del Aparato Digestivo. Hospital de Sagunto, Valencia, España
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D'Amico F, Wexner SD, Vaizey CJ, Gouynou C, Danese S, Peyrin-Biroulet L. Tools for fecal incontinence assessment: lessons for inflammatory bowel disease trials based on a systematic review. United European Gastroenterol J 2020; 8:886-922. [PMID: 32677555 DOI: 10.1177/2050640620943699] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
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.
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Affiliation(s)
- Ferdinando D'Amico
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston USA
| | | | - Célia Gouynou
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Silvio Danese
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
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Transcutaneous Neuromodulation at ST36 (Zusanli) is More Effective than Transcutaneous Tibial Nerve Stimulation in Treating Constipation. J Clin Gastroenterol 2020; 54:536-544. [PMID: 30720579 DOI: 10.1097/mcg.0000000000001184] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND GOALS Combined transcutaneous neuromodulation (TN) at acupoint ST36 (Zusanli) and TN at the posterior tibial nerve (PTN) has been reported effective in treating functional constipation. This study was designed to compare the effectiveness of TN between these 2 points. MATERIALS AND METHODS Eighteen functional constipation patients (M/F: 9/9) were recruited to participate in a cross-over study with a 2-week TN at ST36 and a 2-week TN at PTN. A bowel movement diary, and the questionnaires of Patient Assessment of Constipation Symptom (PAC-SYM) and Constipation Quality of Life (PAC-QoL) were completed; anorectal manometry and spectral analysis of heart rate variability for assessing the autonomic function were performed. RESULTS (1) Both TN at ST36 and TN at PTN improved constipation-related symptoms (PAC-SYM scores on pre-TN vs. post-TN: 1.4±0.1 vs. 0.6±0.1 for ST36, 1.4±0.1 vs. 0.9±0.1 for PTN, both P≤0.001). (2) TN at ST36, but not TN at PTN, increased the number of weekly spontaneous bowel movements (0.9±0.2 pre-TN vs. 3.5±0.7 post-TN, P<0.001) and decreased the total PAC-QoL score. TN at ST36 was more potent than TN at PTN in improving the PAC-SYM score (decrement 0.8±0.1 vs. 0.5±0.1, P<0.05). (3) TN at ST36 rather than TN at PTN resulted in a reduction in sensation thresholds, including rectal distention for urge (134.1±14.3 mL pre-TN vs. 85.6±6.5 mL post-TN, P<0.01) and maximum tolerance (P<0.05). (4) Both TN at ST36 and TN at PTN significantly increased vagal activity and decreased sympathetic activity (P<0.05). CONCLUSIONS TN at ST36 is more potent than TN at PTN in treating constipation and improving constipation-related symptoms and rectal sensation.
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Pregnancy in Women With Prior Treatments for Pelvic Floor Disorders. Female Pelvic Med Reconstr Surg 2020; 26:299-305. [DOI: 10.1097/spv.0000000000000822] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Southwell BR. Electro‐Neuromodulation for Colonic Disorders—Review of Meta‐Analyses, Systematic Reviews, and RCTs. Neuromodulation 2020; 23:1061-1081. [DOI: 10.1111/ner.13099] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 10/30/2019] [Accepted: 12/11/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Bridget R. Southwell
- Surgical Research Group Murdoch Children's Research Institute Melbourne Australia
- Department of Urology Royal Children's Hospital Melbourne Australia
- Department of Paediatrics University of Melbourne Melbourne Australia
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Álamo Vera V, González Oria MO, Carvajal Ramos E, Murciano Casas MP, Guillen Haynes C, García Obrero MI. [Percutaneous posterior tibial nerve electrostimulation in urge urinary incontinence and faecal incontinence]. Rehabilitacion (Madr) 2020; 54:3-10. [PMID: 32007180 DOI: 10.1016/j.rh.2019.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 05/24/2019] [Accepted: 06/24/2019] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The main aim of this study was to assess the efficacy of percutaneous posterior tibial nerve electrostimulation (P-PTNS) in urge urinary incontinence (UUI) and faecal incontinence (FI) refractory to first-line treatment. A secondary aim was to identify predictors of treatment response. To do this, we performed a 2-year analytical, longitudinal and prospective study in patients with UUI and FI treated with P-PTNS. MATERIAL AND METHODS We included patients with UUI and FI who were treated with P-PTNS and who completed the bladder/faecal incontinence diary and severity and quality of life questionnaires. We excluded patients with neurogenic UUI and those who abandoned treatment or did not complete the questionnaires. We assessed demographic and clinical variables (micturition/defecation habits pre- and postreatment), severity scales before and after treatment (ICIQ-SF, Sandvick and Wexner), subjective improvement and quality of life (IQOL and FIQL pre- and postreatment). The statistical analysis was conducted using SPSS v19. RESULTS The sample consisted of 21 patients divided into 2 groups: -UUI group, 9 patients. After P-PTNS, there was a statistically significant improvement in diurnal (p=.018) and nocturnal (p=.016) urinary frequency, urgencies/day (p=.018), urine leakage/day (p=.027), ICIQ-SF and Sandvick (p=.018), and IQOL (p=.012). This improvement was related to exercise (p=.039) and prolapse (p=.05). -Group FI, 12 patients. After P-PTNS, there was a statistically significant improvement in defecation frequency (p=.027), incontinence (p=.012), Wexner scale (p=.007), and FIQL in its 4 dimensions (lifestyle, behaviour, embarrassment p=.005; and depression p=.008). This improvement was related to age (p=.048), time since onset (p=.044) and prolapse (p=.026). CONCLUSIONS The P-PTNS is effective in UUI and FI refractory to conventional treatment. Treatment response is affected by several factors.
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Affiliation(s)
- V Álamo Vera
- Unidad de Gestión Clínica de Rehabilitación, Hospital Universitario Virgen del Rocío, Sevilla, España.
| | - M O González Oria
- Unidad de Gestión Clínica de Rehabilitación, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - E Carvajal Ramos
- Unidad de Gestión Clínica de Rehabilitación, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - M P Murciano Casas
- Unidad de Gestión Clínica de Rehabilitación, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - C Guillen Haynes
- Unidad de Gestión Clínica de Rehabilitación, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - M I García Obrero
- Unidad de Gestión Clínica de Rehabilitación, Hospital Universitario Virgen del Rocío, Sevilla, España
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15
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Solon JG, Waudby P, O'Grady H. Percutaneous tibial nerve stimulation can improve symptoms and quality of life in selected patients with faecal incontinence - A single-centre 5-year clinical experience. Surgeon 2019; 18:154-158. [PMID: 31699593 DOI: 10.1016/j.surge.2019.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 07/24/2019] [Accepted: 08/18/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Faecal incontinence is a debilitating condition that affects a significant proportion of the population. Conservative management remains the mainstay of treatment but surgical intervention such as neuromodulation can be indicated in cases refractory to medical therapy. AIM The aim of this study was to review the outcomes of patients who underwent percutaneous tibial nerve stimulation (PTNS) for faecal incontinence and urgency in a single institution over five years. RESULTS Eighty-one patients completed the 12-week trial of PTNS with a success rate of 80% (n = 64/81). Rates of faecal incontinence and urgency were reduced from 13 episodes per fortnight to 3 and from 10 to 3 respectively. Over a median follow up of 2 years (range 0-5 years) reduction in rates of faecal urgency and incontinence were maintained. Quality of life parameters were measured using a variety of established questionnaires. Improvements were observed in the majority of parameters that were maintained throughout the follow up period. CONCLUSION Percutaneous tibial nerve stimulation is one of the forms of neuromodulation available for the treatment of faecal incontinence and urgency in patients who failed conservative management. This study has shown that in carefully selected, motivated patients, the use of PTNS in conjunction with regular counseling from a specialist practitioner in pelvic floor disorders can improve both the symptoms and quality of life of patients with faecal urgency and mild faecal incontinence with improvements in symptomology maintained for up to 5 years.
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Affiliation(s)
- J G Solon
- Department of Colorectal Surgery, Castle Hill Hospital, HU16 5JQ, England, United Kingdom
| | - P Waudby
- Department of GI Physiology, Castle Hill Hospital, HU16 5JQ, England, United Kingdom
| | - H O'Grady
- Department of Colorectal Surgery, Castle Hill Hospital, HU16 5JQ, England, United Kingdom; Department of GI Physiology, Castle Hill Hospital, HU16 5JQ, England, United Kingdom.
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16
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Huang Y, Koh CE. Sacral nerve stimulation for bowel dysfunction following low anterior resection: a systematic review and meta-analysis. Colorectal Dis 2019; 21:1240-1248. [PMID: 31081580 DOI: 10.1111/codi.14690] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 04/12/2019] [Indexed: 02/08/2023]
Abstract
AIM Low anterior resection syndrome (LARS) can affect up to 70% of all patients with rectal cancer. In the last two decades, sacral nerve stimulation (SNS) has emerged as an effective treatment for faecal incontinence. There is some encouraging literature on the use of SNS in patients with LARS. The purpose of this review is to provide an up to date review on the utility of SNS on LARS. METHOD A literature search was conducted using the MEDLINE, Embase and PubMed databases (January 1981-March 2019). Studies identified were appraised with standard selection criteria. Data points were extracted, and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. RESULTS Ten studies met the inclusion criteria and were included in this study. All studies used the Cleveland Clinic Incontinence Score (CCIS), whereas the low anterior resection syndrome score (LARS score) was used in three studies. Overall median improvement in the scoring system was 67.0% (range 35.5%-88.2%) after SNS implantation. There was a significant reduction in CCIS after SNS implantation (mean difference 11.23, 95% confidence interval 9.38-13.07, Z = 11.90, P < 0.00001). The LARS score was also significantly reduced after using SNS in patients with LARS (mean difference 17.87, 95% confidence interval 10.15-25.59, Z = 4.54, P < 0.00001). CONCLUSION Use of SNS may provide symptomatic benefits for patients with LARS refractory to medical therapy. However, the current level of evidence remains limited. A large multicentre study of SNS for LARS using the validated LARS score is warranted. In addition, the cost-effectiveness of SNS for patients with LARS needs further exploration.
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Affiliation(s)
- Y Huang
- SOuRCe (Surgical Outcomes Research Centre), Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - C E Koh
- SOuRCe (Surgical Outcomes Research Centre), Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
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17
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Rodríguez Carrillo R, Ruiz Carmona MD, Alós Company R, Frangi Caregnato A, Alarcón Iranzo M, Solana Bueno A, Lozoya Trujillo R, García-Granero Ximénez E. Evaluation of the anorectal motor response after percutaneous stimulation of the posterior tibial nerve in patients with fecal incontinence. Tech Coloproctol 2019; 23:987-992. [PMID: 31538295 DOI: 10.1007/s10151-019-02092-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 09/12/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND The effect of posterior tibial nerve stimulation (PTNS) on the mechanisms of anal continence has not been fully demonstrated. The aim of this study was to assess the anal manometric response after percutaneous PTNS in patients with fecal incontinence (FI). METHODS This was a prospective study in patients with FI undergoing 1 weekly session of percutaneous PTNS for 8 weeks. A clinical assessment (Wexner scale) and a complete study of up to 22 manometric parameters were carried out prior to treatment and 2-4 weeks after the end of treatment. RESULTS A total of 32 patients were evaluated. After therapy, there was a decrease in the average Wexner score [12.6 (± 5.2) to 9.5 (± 5.2) (P < 0.005)] and an increase in the "anal canal length at rest" [4.55 (± 0.60) to 4.95 (± 0.21) P = 0.004], without observing variations in other manometric parameters. The decrease in the Wexner score was significantly correlated with an increase in the "pressure at 5 cm at rest" after therapy (r = 0.464 P = 0.030). CONCLUSIONS In our study, PTNS was associated with a significant decrease in the Wexner score and with an increase in the functional length of the anal canal at rest. The improvement in the Wexner scale was correlated with an increase in pressure at rest in the theoretical area of the anorectal junction.
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Affiliation(s)
- R Rodríguez Carrillo
- Servicio de Cirugía General y del Aparato Digestivo, Hospital de Sagunto, Valencia, Spain.
| | - M D Ruiz Carmona
- Servicio de Cirugía General y del Aparato Digestivo, Hospital de Sagunto, Valencia, Spain
| | - R Alós Company
- Servicio de Cirugía General y del Aparato Digestivo, Hospital de Sagunto, Valencia, Spain
| | - A Frangi Caregnato
- Servicio de Cirugía General y del Aparato Digestivo, Hospital de Sagunto, Valencia, Spain
| | - M Alarcón Iranzo
- Servicio de Cirugía General y del Aparato Digestivo, Hospital de Sagunto, Valencia, Spain
| | - A Solana Bueno
- Servicio de Cirugía General y del Aparato Digestivo, Hospital de Sagunto, Valencia, Spain
| | - R Lozoya Trujillo
- Servicio de Cirugía General y del Aparato Digestivo, Hospital de Sagunto, Valencia, Spain
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18
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Murad-Regadas SM, Regadas FSP, Regadas Filho FSP, Mendonça Filho JJD, Andrade Filho RS, Vilarinho ADS. PREDICTORS OF UNSUCCESSFUL OF TREATMENT FOR FECAL INCONTINENCE BIOFEEDBACK FOR FECAL INCONTINENCE IN FEMALE. ARQUIVOS DE GASTROENTEROLOGIA 2019; 56:61-65. [PMID: 31141067 DOI: 10.1590/s0004-2803.201900000-17] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 02/27/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Biofeedback is an effective method of treatment for fecal incontinence but there is controversy regarding factors that may be correlated with its effectiveness. OBJECTIVE To evaluate the efficacy of biofeedback in the treatment of fecal incontinence, identifying the predictive factors for unsuccessful treatment. METHODS Consecutive female patients who had fecal incontinence and were treated with a full course of biofeedback were screened. The symptoms were evaluated using Cleveland Clinic incontinence (CCF) score before and six months after the completion of therapy. Patients had a satisfactory clinical response to biofeedback if the CCF score had decreased by more than 50% at six months (GI) and an unsatisfactory response if the CCF score did not decrease or if the score decreased by <50% (GII). The groups were compared with regard to age, score, anal resting and squeeze pressures and sustained squeeze pressure by manometry, history of vaginal delivery, number of vaginal deliveries, menopause, hysterectomy, and previous anorectal surgery. RESULTS Of 124 women were included, 70 (56%) in GI and 54 (44%) in GII. The median CCF score decreased significantly from 10 to 5 (P=0.00). FI scores were higher in GII. Patients from GII had more previous vaginal deliveries and previous surgeries. The mean sustained squeeze pressure was higher in GI. Patients from GI and GII had similar ages, number of vaginal deliveries, menopause, hysterectomy, anal pressures, and sphincter defects. The median sustained squeeze pressure increased significantly before and after biofeedback in GI. CONCLUSION Biofeedback therapy shows effective treatment with 50% reductions in FI score in half of patients. Factors associated with unsuccessful outcome include FI score ≥10, previous vaginal delivery, previous anorectal and/or colorectal surgery, and reduced mean sustained squeeze pressure.
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Affiliation(s)
- Sthela M Murad-Regadas
- Universidade Federal do Ceará, Faculdade de Medicina, Departamento de Cirurgia, Fortaleza, CE, Brasil.,Universidade Federal do Ceará, Hospital das Clínicas, Unidade de Piso Pélvico e Fisiologia Anorretal, Fortaleza, CE, Brasil.,Hospital São Carlos, Departamento de Cirurgia Colorretal, Unidade de Piso Pélvico e Fisiologia Anorretal, CE, Brasil
| | | | | | | | - Roberto S Andrade Filho
- Hospital São Carlos, Departamento de Cirurgia Colorretal, Unidade de Piso Pélvico e Fisiologia Anorretal, CE, Brasil
| | - Adjra da Silva Vilarinho
- Hospital São Carlos, Departamento de Cirurgia Colorretal, Unidade de Piso Pélvico e Fisiologia Anorretal, CE, Brasil
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19
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Dedemadi G, Takano S. Efficacy of Bilateral Transcutaneous Posterior Tibial Nerve Stimulation for Fecal Incontinence. Perm J 2019; 22:17-231. [PMID: 30028671 DOI: 10.7812/tpp/17-231] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
CONTEXT Posterior tibial nerve stimulation is a new second-line treatment for refractory fecal incontinence. OBJECTIVE To assess the efficacy of bilateral transcutaneous posterior tibial nerve stimulation (BTPTNS) for treatment of fecal incontinence in Japanese patients and its impact on quality of life. DESIGN A prospective observational-interventional study was conducted from May 2015 to June 2017 in patients with fecal incontinence in whom conservative treatment had failed. All patients received a 30-minute session of stimulation twice weekly for 6 consecutive weeks. Evaluation at baseline and at 6 weeks involved the Wexner score, Fecal Incontinence Quality of Life (FIQL) questionnaire, and anal manometry. Patients recorded episodes of incontinence in a weekly diary. MAIN OUTCOME MEASURES Reduction of 50% or greater in incontinence episodes, decreased Wexner score, and improved FIQL scores. RESULTS Twenty-two patients with a median age of 64.1 years (range, 26-81 years) and men:women ratio of 9:13 completed BTPTNS. Mean episodes of fecal incontinence were significantly reduced from 4.7 to 1.5 (p < 0.05). An improvement of 50% or better in episodes of fecal incontinence was achieved in 77.2% of patients. The median Wexner score significantly decreased from 10.2 to 6.9 (p < 0.05). The median FIQL score improved from 2.7 to 3.1 (p = 0.06), and significant improvement was seen in the embarrassment domain (2.2 vs 2.8, p < 0.05). Resting and squeezing anal pressures revealed no significant changes. CONCLUSION Our findings suggest that BTPTNS is safe and well tolerated and may improve symptoms of fecal incontinence. This technique offers an additional noninvasive, less expensive form of treatment.
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Affiliation(s)
- Georgia Dedemadi
- Surgeon in the Department of Functional Anorectal Disorders at Coloproctology Center Takano Hospital in Kumamoto City, Japan, and a Surgeon in the Department of Surgery at Sismanoglio-Amalia Fleming Hospital in Athens, Greece.
| | - Shota Takano
- Surgeon in the Department of Functional Anorectal Disorders at Coloproctology Center Takano Hospital in Kumamoto City, Japan.
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20
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Matzel KE, Bittorf B. Reprint of: Management of fecal incontinence: Surgical treatement. SEMINARS IN COLON AND RECTAL SURGERY 2018. [DOI: 10.1053/j.scrs.2018.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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21
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Sanagapalli S, Harrington S, Zarate-Lopez N, Emmanuel A. Posterior Tibial Nerve Stimulation for the Treatment of Fecal Incontinence Following Obstetric Anal Sphincter Injury. Neuromodulation 2018; 21:688-693. [DOI: 10.1111/ner.12844] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 05/08/2018] [Accepted: 06/04/2018] [Indexed: 12/12/2022]
Affiliation(s)
- Santosh Sanagapalli
- GI Physiology Unit; University College London Hospital; London UK
- Department of Gastroenterology; St Vincent's Hospital Sydney; Darlinghurst NSW Australia
- St Vincent's Clinical School; University of New South Wales; Sydney NSW Australia
| | | | | | - Anton Emmanuel
- GI Physiology Unit; University College London Hospital; London UK
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22
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Heywood NA, Pearson JS, Nicholson JE, Molyneux C, Sharma A, Kiff ES, Whorwell PJ, Telford KJ. The short-term effects of posterior tibial nerve stimulation on anorectal physiology in patients with faecal incontinence: a single centre experience. Therap Adv Gastroenterol 2018; 11:1756284818786111. [PMID: 30034533 PMCID: PMC6048664 DOI: 10.1177/1756284818786111] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 06/06/2018] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Posterior tibial nerve stimulation (PTNS) is a novel treatment for patients with faecal incontinence (FI) and may be effective in selected patients; however, its mechanism of action is unknown. We sought to determine the effects of PTNS on anorectal physiological parameters. METHODS Fifty patients with FI underwent 30 min of PTNS treatment, weekly for 12 weeks. High-resolution anorectal manometry, bowel diaries and Vaizey questionnaires were performed before and after treatment. Successful treatment was determined as a greater than 50% reduction in FI episodes. RESULTS Fifty patients with FI were studied; 39 women, median age 62 years (range 30-82). Compared with pretreatment, there were reductions in episodes of urgency (16.0 versus 11.4, p = 0.006), overall FI (14.5 versus 9.1, p = 0.001), urge FI (5.4 versus 3.2, p = 0.016) and passive FI (9.1 versus 5.9, p = 0.008). Vaizey score was reduced (16.1 versus 14.5, p = 0.002). Rectal sensory volumes (ml) decreased (onset 40.3 versus 32.6, p = 0.014, call 75.7 versus 57.5, p < 0.001, urge 104.1 versus 87.4, p = 0.004). There was no significant change in anal canal pressures (mmHg) (maximum resting pressure 41.4 versus 44.2, p = 0.39, maximum squeeze pressure, 78.7 versus 88.2, p = 0.15, incremental squeeze pressure 37.2 versus 44.1, p = 0.22). Reduction in FI episodes did not correlate with changes in physiological parameters (p > 0.05). Treatment success of 44% was independent of changes in manometric parameters (p > 0.05). CONCLUSIONS PTNS has a measureable physiological effect on rectal sensory volumes without an effect on anal canal pressures. It also reduces FI episodes; however, this effect is independent of changing physiology, suggesting that PTNS has a complex mechanism of action.
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Affiliation(s)
| | | | | | | | | | | | - Peter J. Whorwell
- University Hospital of South Manchester &
Manchester University, Manchester, UK
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23
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Abstract
Faecal incontinence is a condition that can develop as a result of age, injury or long-term conditions, and may be associated with significant stigma for those affected. Symptoms of faecal incontinence include leakage of flatus and faeces, and the condition can affect people of any age, although it is most prevalent in older people. Faecal incontinence is a subject that might not be openly discussed by patients and healthcare professionals; therefore, it is important for nurses to be aware of its signs, symptoms, causes and risk factors, so that they can identify patients at high risk. This article provides an overview of faecal incontinence, exploring its causes, psychological effects for patients, and conservative and specialised management measures, as well as the nurse's role in providing treatment and support.
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Affiliation(s)
- Mariama Barrie
- Continence Advisory Service, Wokingham Community Hospital, Berkshire Healthcare NHS Foundation Trust, Berkshire, England
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24
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Arroyo Fernández R, Avendaño Coy J, Ando Lafuente S, Martín Correa MT, Ferri Morales A. Posterior tibial nerve stimulation in the treatment of fecal incontinence: a systematic review. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2018; 110:577-588. [DOI: 10.17235/reed.2018.5007/2017] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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25
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McCawley N, O'Connell PR. Neuromodulation for low-anterior resection syndrome. COLORECTAL CANCER 2017. [DOI: 10.2217/crc-2017-0012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Niamh McCawley
- School of Medicine & Medical Sciences, University College Dublin, Belfield, Dublin 4 D04 T6F4, Ireland
- Surgical Professorial Unit & Department of Colorectal Surgery, St Vincent's University Hospital, Elm Park, Nutley Lane, Dublin D04 T6F4, Ireland
| | - P Ronan O'Connell
- School of Medicine & Medical Sciences, University College Dublin, Belfield, Dublin 4 D04 T6F4, Ireland
- Surgical Professorial Unit & Department of Colorectal Surgery, St Vincent's University Hospital, Elm Park, Nutley Lane, Dublin D04 T6F4, Ireland
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26
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van der Wilt AA, Giuliani G, Kubis C, van Wunnik BPW, Ferreira I, Breukink SO, Lehur PA, La Torre F, Baeten CGMI. Randomized clinical trial of percutaneous tibial nerve stimulation versus sham electrical stimulation in patients with faecal incontinence. Br J Surg 2017; 104:1167-1176. [PMID: 28703936 DOI: 10.1002/bjs.10590] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 01/18/2017] [Accepted: 04/06/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND The aim was to assess the effects of percutaneous tibial nerve stimulation (PTNS) in the treatment of faecal incontinence (FI) by means of an RCT. METHODS Patients aged over 18 years with FI were included in a multicentre, single-blinded RCT. The primary endpoint was reduction in the median or mean number of FI episodes per week. Secondary endpoints were changes in measures of FI severity, and disease-specific and generic quality of life. Outcomes were compared between PTNS and sham stimulation after 9 weeks of treatment. RESULTS A higher proportion of patients in the PTNS (13 of 29) than in the sham (6 of 30) group showed a reduction of at least 50 per cent in the median number of FI episodes/week (incidence rate ratio (IRR) 2·40, 95 per cent c.i. 1·10 to 5·24; P = 0·028), but not in the mean number of episodes/week (10 of 29 versus 8 of 30; IRR 1·42, 0·69 to 2·92; P = 0·347). The absolute median number of FI episodes per week decreased in the PTNS but not in the sham group (IRR 0·66, 0·44 to 0·98; P = 0·041), as did the mean number (IRR 0·65 (0·45 to 0·97); P = 0·034). Scores on the Cleveland Clinic Florida faecal incontinence scale decreased significantly in both groups, but more steeply in the PTNS group (mean difference -1·3, 95 per cent c.i. -2·6 to 0·0; P = 0·049). The aggregated mental component score of Short Form 36 improved in the PTNS but not in the sham group (mean difference 5·1, 0·5 to 9·6; P = 0·028). CONCLUSION PTNS may offer a small advantage in the clinical management of FI that is insufficiently responsive to conservative treatment. The key challenge will be to identify patients who may benefit most from this minimally invasive surgical procedure. Registration number: NCT00974909 (http://www.clinicaltrials.gov).
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Affiliation(s)
- A A van der Wilt
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - G Giuliani
- Department of Surgery, Università degli Studi di Roma 'Sapienza', Rome, Italy
| | - C Kubis
- Department of Surgery, Institut des Maladies de l'Appareil Digestiv, University Hospital of Nantes, Nantes, France
| | - B P W van Wunnik
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - I Ferreira
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands.,Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - S O Breukink
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - P A Lehur
- Department of Surgery, Institut des Maladies de l'Appareil Digestiv, University Hospital of Nantes, Nantes, France
| | - F La Torre
- Department of Surgery, Università degli Studi di Roma 'Sapienza', Rome, Italy
| | - C G M I Baeten
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
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27
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Percutaneous tibial nerve stimulation (pTNS): success rate and the role of rectal capacity. Int J Colorectal Dis 2017; 32:789-796. [PMID: 28391449 DOI: 10.1007/s00384-017-2804-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE Percutaneous tibial nerve stimulation (pTNS) was originally developed to treat urinary incontinence. Recently, some case series have also documented its success in the treatment of fecal incontinence. Nevertheless, the mechanism underlying this effect remains unknown but may be related to changes in rectal capacity. The aim of this study was to investigate the success of pTNS for the treatment of fecal urge incontinence and assess the influence of rectal capacity on treatment efficacy. METHODS All patients undergoing pTNS for fecal incontinence between July 2009 and March 2014 were enrolled in a prospective, observational study consisting of a therapeutic regimen that lasted 9 months. Therapy success was defined as a reduction in the CCI (Cleveland Clinic incontinence) score of ≥50% and patient-reported success. Furthermore, quality of life (Rockwood's scale) and changes in anorectal physiology were recorded. RESULTS Fifty-seven patients with fecal urge incontinence were eligible, nine of whom were excluded. The success rate was 72.5%. Incontinence events and urge symptoms were significantly reduced after 3 months and at the end of therapy. The median CCI score decreased from 12 to 4 (P < 0.0001), and the quality of life was significantly improved. However, rectal capacity was not significantly related to treatment success before or after therapy. No adverse events were observed. CONCLUSIONS These results demonstrate that pTNS can improve the symptoms and quality of life of patients with fecal urge incontinence. However, the study fails to demonstrate a correlation between treatment success and changes in rectal capacity.
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28
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Vigorita V, Rausei S, Troncoso Pereira P, Trostchansky I, Ruano Poblador A, Moncada Iribarren E, Facal Alvarez C, de San Ildefonso Pereira A, Casal Núñez E. A pilot study assessing the efficacy of posterior tibial nerve stimulation in the treatment of low anterior resection syndrome. Tech Coloproctol 2017; 21:287-293. [PMID: 28439675 DOI: 10.1007/s10151-017-1608-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Accepted: 03/02/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Low anterior resection for rectal cancer often results in severe bowel dysfunction, specifically low anterior resection syndrome (LARS), with symptoms such as incontinence, urgency, and frequent bowel movements. Percutaneous tibial nerve stimulation (PTNS) resulted in a high rate of success in patients with fecal incontinence. The aim of this study was to evaluate the effectiveness of treatment with PTNS in LARS and to identify predictors of the outcome of the technique. METHODS The study was conducted from May 2012 to April 2015 at the Alvaro Cunqueiro Hospital, University Hospital Complex of Vigo, Spain. Ten patients with LARS were recruited consecutively. All patients underwent 2 sessions per week (30 min each one) for 6 weeks. Patients were followed for 3 weeks, and those who had a significant clinical improvement were recruited to a second phase of PTNS. Some patients presenting with relapse during follow-up underwent an additional phase of PTNS. Outcome measures included Wexner scores, quality of life scores, and urgency of defecation. RESULTS Three patients did not complete the treatment due to poor response in the first phase. Incontinence was reduced in the remaining seven of ten patients. The median Wexner score at initial patient evaluation was 14 (IQR 10.75-18.5), which decreased to 10 (IQR 6.5-18) after treatment (p = 0.034). A statistically significant improvement was demonstrated in quality of life scale, lifestyle, depression, and daily defecation urgency (p < 0.05). LARS Score improvement was observed in five patients (50%) with a total resolution of LARS in 2 (20%). CONCLUSIONS PTNS is an ambulatory treatment that could play an important role in the context of a multimodal treatment approach in patients with LARS. It could be a first-line treatment to identify non-responders to conservative management who need different and more invasive treatments.
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Affiliation(s)
- V Vigorita
- Division of Coloproctology, Department of General and Digestive Surgery, University Hospital Complex of Vigo - Alvaro Cunqueiro Hospital, Estrada Clara Campoamor, 341, 36312, Vigo (Beade), Pontevedra, Spain.
| | - S Rausei
- Department of Surgery, University of Insubria, Varese, Italy
| | - P Troncoso Pereira
- Division of Coloproctology, Department of General and Digestive Surgery, University Hospital Complex of Vigo - Alvaro Cunqueiro Hospital, Estrada Clara Campoamor, 341, 36312, Vigo (Beade), Pontevedra, Spain
| | - I Trostchansky
- Division of Coloproctology, Department of General and Digestive Surgery, University Hospital Complex of Vigo - Alvaro Cunqueiro Hospital, Estrada Clara Campoamor, 341, 36312, Vigo (Beade), Pontevedra, Spain
| | - A Ruano Poblador
- Division of Coloproctology, Department of General and Digestive Surgery, University Hospital Complex of Vigo - Alvaro Cunqueiro Hospital, Estrada Clara Campoamor, 341, 36312, Vigo (Beade), Pontevedra, Spain
| | - E Moncada Iribarren
- Division of Coloproctology, Department of General and Digestive Surgery, University Hospital Complex of Vigo - Alvaro Cunqueiro Hospital, Estrada Clara Campoamor, 341, 36312, Vigo (Beade), Pontevedra, Spain
| | - C Facal Alvarez
- Division of Coloproctology, Department of General and Digestive Surgery, University Hospital Complex of Vigo - Alvaro Cunqueiro Hospital, Estrada Clara Campoamor, 341, 36312, Vigo (Beade), Pontevedra, Spain
| | - A de San Ildefonso Pereira
- Division of Coloproctology, Department of General and Digestive Surgery, University Hospital Complex of Vigo - Alvaro Cunqueiro Hospital, Estrada Clara Campoamor, 341, 36312, Vigo (Beade), Pontevedra, Spain
| | - E Casal Núñez
- Division of Coloproctology, Department of General and Digestive Surgery, University Hospital Complex of Vigo - Alvaro Cunqueiro Hospital, Estrada Clara Campoamor, 341, 36312, Vigo (Beade), Pontevedra, Spain
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Horrocks EJ, Bremner SA, Stevens N, Norton C, Gilbert D, O'Connell PR, Eldridge S, Knowles CH. Double-blind randomised controlled trial of percutaneous tibial nerve stimulation versus sham electrical stimulation in the treatment of faecal incontinence: CONtrol of Faecal Incontinence using Distal NeuromodulaTion (the CONFIDeNT trial). Health Technol Assess 2016; 19:1-164. [PMID: 26422980 DOI: 10.3310/hta19770] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Faecal incontinence (FI) is a common condition which is often under-reported. It is distressing for those suffering from it, impacting heavily on their quality of life. When conservative strategies fail, treatment options are limited. Percutaneous tibial nerve stimulation (PTNS) is a minimally invasive outpatient treatment, shown in preliminary case series to have significant effectiveness; however, no randomised controlled trial has been conducted. OBJECTIVES To assess the effectiveness of PTNS compared with sham electrical stimulation in the treatment of patients with FI in whom initial conservative strategies have failed. DESIGN Multicentre, parallel-arm, double-blind randomised (1 : 1) controlled trial. SETTING Eighteen UK centres providing specialist nurse-led (or equivalent) treatment for pelvic floor disorders. PARTICIPANTS Participants aged > 18 years with FI who have failed conservative treatments and whose symptoms are sufficiently severe to merit further intervention. INTERVENTIONS PTNS was delivered via the Urgent(®) PC device (Uroplasty Limited, Manchester, UK), a hand-held pulse generator unit, with single-use leads and fine-needle electrodes. The needle was inserted near the tibial nerve on the right leg adhering to the manufacturer's protocol (and specialist training). Treatment was for 30 minutes weekly for a duration of 12 treatments. Validated sham stimulation involved insertion of the Urgent PC needle subcutaneously at the same site with electrical stimulation delivered to the distal foot using transcutaneous electrical nerve stimulation. MAIN OUTCOME MEASURES Outcome measures were assessed at baseline and 2 weeks following treatment. Clinical outcomes were derived from bowel diaries and validated, investigator-administered questionnaires. The primary outcome classified patients as responders or non-responders, with a responder defined as someone having achieved ≥ 50% reduction in weekly faecal incontinence episodes (FIEs). RESULTS In total, 227 patients were randomised from 373 screened: 115 received PTNS and 112 received sham stimulation. There were 12 trial withdrawals: seven from the PTNS arm and five from the sham arm. Missing data were multiply imputed. For the primary outcome, the proportion of patients achieving a ≥ 50% reduction in weekly FIEs was similar in both arms: 39 in the PTNS arm (38%) compared with 32 in the sham arm (31%) [odds ratio 1.28, 95% confidence interval (CI) 0.72 to 2.28; p = 0.396]. For the secondary outcomes, significantly greater decreases in weekly FIEs were observed in the PTNS arm than in the sham arm (beta -2.3, 95% CI -4.2 to -0.3; p = 0.02), comprising a reduction in urge FIEs (p = 0.02) rather than passive FIEs (p = 0.23). No significant differences were found in the St Mark's Continence Score or any quality-of-life measures. No serious adverse events related to treatment were reported. CONCLUSIONS PTNS did not show significant clinical benefit over sham electrical stimulation in the treatment of FI based on number of patients who received at least a 50% reduction in weekly FIE. It would be difficult to recommend this therapy for the patient population studied. Further research will concentrate on particular subgroups of patients, for example those with pure urge FI. TRIAL REGISTRATION Current Controlled Trials ISRCTN88559475. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 77. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Emma J Horrocks
- National Centre for Bowel Research and Surgical Innovation, Blizard Institute, Queen Mary University of London, London, UK
| | - Stephen A Bremner
- Pragmatic Clinical Trials Unit, Blizard Institute, Queen Mary University of London, London, UK
| | - Natasha Stevens
- Pragmatic Clinical Trials Unit, Blizard Institute, Queen Mary University of London, London, UK
| | - Christine Norton
- Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, UK
| | - Deborah Gilbert
- National Centre for Bowel Research and Surgical Innovation, Blizard Institute, Queen Mary University of London, London, UK
| | - P Ronan O'Connell
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| | - Sandra Eldridge
- Pragmatic Clinical Trials Unit, Blizard Institute, Queen Mary University of London, London, UK
| | - Charles H Knowles
- National Centre for Bowel Research and Surgical Innovation, Blizard Institute, Queen Mary University of London, London, UK
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Posterior tibial nerve stimulation for the treatment of fecal incontinence: a systematic evidence review. Obstet Gynecol Surv 2016; 70:329-41. [PMID: 25974730 DOI: 10.1097/ogx.0000000000000171] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
IMPORTANCE AND OBJECTIVES Posterior tibial nerve stimulation (PTNS) is a potential emerging therapy for fecal incontinence (FI). The aim of this study was to systematically review the literature regarding the efficacy of PTNS as a treatment of FI. EVIDENCE ACQUISITION We searched MEDLINE/PubMed, EMBASE, and Cochrane databases from inception through November 2013. We included English-language full-text articles reporting outcomes for FI with either percutaneous PTNS or transcutaneous techniques (transcutaneous electrical nerve stimulation). We used the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system to assess study quality. RESULTS Our search yielded 1154 citations; 129 abstracts and 17 articles were included for full-text review. There were 13 case series and 4 randomized controlled trials. Fifteen studies were of low quality, none were of fair quality, and 2 studies were of good quality based on the Grades of Recommendation, Assessment, Development, and Evaluation system. In total, 745 subjects were studied, and of those, 90% were women and 10% were men. Studies involved percutaneous PTNS in 57% (428/745) of the subjects, transcutaneous electrical nerve stimulation in 30% (223/745), and sham technique in 13% (94/745). Therapy frequency, maintenance therapy, and follow-up time varied across studies. Eleven studies assessed FI episodes and bowel movement deferment time; all but 1 showed statistical improvement after therapy. Ten of the 11 studies that used the Cleveland Clinic Florida Fecal Incontinence score reported statistically significantly improved scores after treatment. CONCLUSIONS AND RELEVANCE Multiple low-quality studies show improvement in FI after PTNS. High-quality studies with comparison groups and clinically meaningful outcome measures would further establish the utility of PTNS for FI.
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Jiménez-Toscano M, Vega D, Fernandez-Cebrián JM, Valle Martín B, Jiménez-Almonacid P, Rueda Orgaz JA. Efficacy and quality of life after transcutaneous posterior tibial neuromodulation for faecal incontinence. Colorectal Dis 2015; 17:718-23. [PMID: 25704357 DOI: 10.1111/codi.12923] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 12/22/2014] [Indexed: 12/22/2022]
Abstract
AIM The aim of this study was to evaluate the efficacy of transcutaneous neuromodulation of the posterior tibial nerve for faecal incontinence and to assess quality of life after the procedure. METHOD A prospective non-randomized cohort study was conducted in a tertiary centre from September 2010 to May 2013. All patients with faecal incontinence who met the inclusion criteria were included and were treated as outpatients during a 3-month period by unilateral neuromodulation of the posterior tibial nerve. The patients were followed 3-monthly for 1 year. Severity scales, a bowel diary and quality of life scales were evaluated prospectively before and after treatment. RESULTS Twenty-seven patients of median age 67 (interquartile range 60-69) years and a male to female ratio of 1/6 were included. Faecal incontinence was for solid stools in 48.1% of patients with urgency in 55.6%. About one-third (34.6%) had a sphincter defect on ultrasound and reduction of anal canal pressure in 85.2%. There was a significant improvement in episodes of incontinence on the Wexner score and visual analogue scale assessment and a decrease in the number of episodes of incontinence per unit time. The Fecal Incontinence Quality of Life score was improved at the end of the follow-up. No adverse effects were observed. The cost of the treatment was €135 per patient. CONCLUSION Transcutaneous posterior tibial nerve neuromodulation provides good treatment for faecal incontinence in terms of efficacy and quality of life.
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Affiliation(s)
| | - D Vega
- Surgery Department, Alcorcon University Hospital, Madrid, Spain
| | | | - B Valle Martín
- Physiotherapy Department, Alcorcon University Hospital, Madrid, Spain
| | | | - J A Rueda Orgaz
- Surgery Department, Alcorcon University Hospital, Madrid, Spain
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Abell TL, Chen J, Emmanuel A, Jolley C, Sarela AI, Törnblom H. Neurostimulation of the gastrointestinal tract: review of recent developments. Neuromodulation 2015; 18:221-7; discussion 227. [PMID: 25581846 DOI: 10.1111/ner.12260] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Revised: 10/09/2014] [Accepted: 11/03/2014] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Neurostimulation is one manifestation of neuromodulation of the gastrointestinal (GI) tract. This manuscript reviews the history of neurostimulation of the GI tract with emphasis on current methods of stimulation. MATERIALS AND METHODS A review was completed of the current research on GI neurostimulation methods with an emphasis on their clinical applications. RESULTS Upper GI disorders can be modulated with both temporary (placed endoscopically or surgically) or permanent (placed surgically) gastric electrical stimulation (GES) devices. The current GI neurostimulation of stomach (GES) devices have been used in both children and adults, and some patients have been followed in excess of 15 years with good long-term results. Similar GES devices also have been used for a variety of lower GI disorders, including constipation and fecal incontinence, for a number of years. CONCLUSIONS GI neurostimulation, as a type of neuromodulation, has been demonstrated to function at several locations in the GI tract for a variety of disorders. The future of neurostimulation in the GI tract will likely be influenced by a better understanding of pathophysiology as well as the development of new techniques and devices for neuromodulation.
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Affiliation(s)
- Thomas L Abell
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Louisville, Louisville, KY, USA
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Tibial sensory neuropathy as a rare complication of percutaneous tibial nerve stimulation. Int Urogynecol J 2014; 26:301-2. [PMID: 25407114 DOI: 10.1007/s00192-014-2544-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 09/21/2014] [Indexed: 10/24/2022]
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Al Asari S, Meurette G, Mantoo S, Kubis C, Wyart V, Lehur PA. Percutaneous tibial nerve stimulation vs sacral nerve stimulation for faecal incontinence: a comparative case-matched study. Colorectal Dis 2014; 16:O393-9. [PMID: 24911219 DOI: 10.1111/codi.12680] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2014] [Accepted: 05/10/2014] [Indexed: 12/13/2022]
Abstract
AIM The study assessed the initial experience with posterior tibial nerve stimulation (PTNS) for faecal incontinence and compared it with sacral nerve stimulation (SNS) performed in a single centre during the same timespan. METHOD A retrospective review of a prospectively collected database was conducted at the colorectal unit, University Hospital, Nantes, France, from May 2009 to December 2010. Seventy-eight patients diagnosed with chronic severe faecal incontinence underwent neurostimulation including PTNS in 21 and SNS in 57. The main outcome measures were faecal incontinence (Wexner score) and quality of life (Fecal Incontinence Quality of Life, FIQL) scores in a short-term follow-up. RESULTS No significant differences were observed in patients' characteristics. Of 57 patients having SNS, 18 (32%) failed peripheral nerve evaluation and 39 (68%) received a permanent implant. Two (5%) developed a wound infection. No adverse effects were recorded in the PTNS group. There was no significant difference in the mean Wexner and FIQL scores between patients having PTNS and SNS at 6 (P = 0.39 and 0.09) and 12 months (P = 0.79 and 0.37). A 50% or more improvement in Wexner score was seen at 6 and 12 months in 47% and 30% of PTNS patients and in 50% and 58% of SNS patients with no significant difference between the groups. CONCLUSION Posterior tibial nerve stimulation is a valid method of treating faecal incontinence in the short term when conservative treatment has failed. It is easier, simpler, cheaper and less invasive than SNS with a similar short-term outcome.
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Affiliation(s)
- S Al Asari
- Clinique de Chirurgie Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif (IMAD), University Hospital of Nantes, Nantes, France
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Abstract
Fecal incontinence (FI) is a multifactorial disorder that imposes considerable social and economic burdens. The aim of this article is to provide an overview of current and emerging treatment options for FI. A MEDLINE search was conducted for English-language articles related to FI prevalence, etiology, diagnosis, and treatment published from January 1, 1990 through June 1, 2013. The search was extended to unpublished trials on ClinicalTrials.gov and relevant publications cited in included articles. Conservative approaches, including dietary modifications, medications, muscle-strengthening exercises, and biofeedback, have been shown to provide short-term benefits. Transcutaneous electrical stimulation was considered ineffective in a randomized clinical trial. Unlike initial studies, sacral nerve stimulation has shown reasonable short-term effectiveness and some complications. Dynamic graciloplasty and artificial sphincter and bowel devices lack randomized controlled trials and have shown inconsistent results and high rates of explantation. Of injectable bulking agents, dextranomer microspheres in non-animal stabilized hyaluronic acid (NASHA Dx) has shown significant improvement in incontinence scores and frequency of incontinence episodes, with generally mild adverse effects. For the treatment of FI, conservative measures and biofeedback therapy are modestly effective. When conservative therapies are ineffective, invasive procedures, including sacral nerve stimulation, may be considered, but they are associated with complications and lack randomized, controlled trials. Bulking agents may be an appropriate alternative therapy to consider before more aggressive therapies in patients who fail conservative therapies.
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Abstract
Fecal incontinence (FI) is a devastating condition affecting a substantial portion of the population. The etiologies of FI are wide ranging, as are the treatment options. When conservative measures fail, often surgical intervention is required. As in any area where a wide range of treatment options exist, there is no one perfect solution. Fortunately, novel treatment options for FI are becoming available, namely, posterior tibial nerve stimulation, magnetic anal sphincter, stem cell transplant, pyloric transplantation, and acupuncture.
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Affiliation(s)
- Adam Barker
- Department of Colon and Rectal Surgery, Presbyterian Hospital, Dallas, Texas
| | - Jefferson Hurley
- Department of Colon and Rectal Surgery, Presbyterian Hospital, Dallas, Texas
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López-Delgado A, Arroyo A, Ruiz-Tovar J, Alcaide MJ, Diez M, Moya P, Santos J, Calpena R. Effect on anal pressure of percutaneous posterior tibial nerve stimulation for faecal incontinence. Colorectal Dis 2014; 16:533-7. [PMID: 24674305 DOI: 10.1111/codi.12628] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 02/28/2014] [Indexed: 02/08/2023]
Abstract
AIM Previous studies on percutaneous posterior tibial nerve stimulation (PTNS) for faecal incontinence do not report anal pressure changes. In the present study the effect of percutaneous PTNS on anal manometry was determined. METHOD This was a prospective observational study of patients with faecal incontinence. They underwent one 30-min session of PTNS weekly for 12 consecutive weeks. Patients who showed improvement were given six more sessions at 2-weekly intervals. Anal manometry was performed before and after treatment. Clinical data including the Wexner score, psychological testing, quality of life using the Fecal Incontinence Quality of Life Score and the contents of a continence diary were recorded before and after the procedure. RESULTS Twenty-four patients were included in the study of whom 17 (70.83%) demonstrated some degree of clinical or manometric improvement at 3 months. Before treatment 18 patients had urgency of <1 min. At 3 and 6 months this had risen to 5 min in 62.5% and 70.83% (P < 0.001). The anal resting pressure increased from 21.7 to 37.6 mmHg (P = 0.021), the maximum squeeze pressure from 58.2 to 72.2 mmHg (P = 0.045) and the Wexner score fell from 15 to 10 (P = 0.018) at 6 months. Predictive factors for a response included fewer than three incontinent episodes per week (P = 0.027). Negative predictive factors included episiotomy and an initial Wexner score of > 12 (P = 0.035). CONCLUSION Percutaneous PTNS was effective in over 70% of patients in the present study with improvements in urgency, anal pressures and Wexner score.
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Affiliation(s)
- A López-Delgado
- Coloproctology Unit, Department of Surgery, University Hospital of Elche, Elche, Alicante, Spain
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Outcome of percutaneous tibial nerve stimulation (PTNS) for fecal incontinence: a prospective cohort study. Ann Surg 2014; 259:939-43. [PMID: 23979291 DOI: 10.1097/sla.0b013e3182a6266c] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES The aim of this study was to assess the long-term efficacy of percutaneous tibial nerve stimulation (PTNS) in fecal incontinence (FI). BACKGROUND There is extensive evidence regarding the efficacy of PTNS in urinary incontinence. Data on the efficacy of PTNS for FI are limited to a few small case series with relatively short-follow up. METHODS A prospective cohort of patients with FI was studied. Incontinence scores were measured using a validated questionnaire (Cleveland Clinic Florida-FI score) at specific time points: before treatment, after completion of a treatment course (12 PTNS sessions), and before the last maintenance ("top-up") therapy. Deferment time and average number of weekly incontinence episodes were also estimated from a prospective bowel dairy kept by the patient at these time points. Quality of life was assessed with the Rockwood Fecal Incontinence Quality of Life questionnaire. RESULTS A total of 150 patients were recruited to the study between January 2008 and June 2012. Analysis was performed on 115 patients who continued to receive PTNS after a median follow-up of 26 (range, 12-42) months. The baseline Cleveland Clinic Florida-FI score ±SD (12.0 ± 3.9) improved after 12 PTNS sessions (9.4 ± 4.6, P < 0.0001) and after "top-up" treatments (10.0 ± 4.3, P < 0.0001). The increase in the Cleveland Clinic Florida-FI score between the end of the 12th session and the last "top-up" therapy was also significant (P = 0.04). A similar pattern was seen for the deferment time and the quality of life scores. The median time between "top-up" sessions was 12 months (range, 1-40 months), significantly longer than the recommended interval of 6 months. CONCLUSIONS PTNS is a well-tolerated treatment with high acceptability in the majority of patients. It provides a sustained improvement in FI up to 42 months in a relatively noninvasive manner. The effect of PTNS diminishes with time and additional therapy sessions at 6 monthly intervals may result in greater improvements. PTNS ought to be considered as the first step in all patients with FI refractory to maximum conservative therapies.
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Hotouras A, Murphy J, Allison M, Curry A, Williams NS, Knowles CH, Chan CL. Prospective clinical audit of two neuromodulatory treatments for fecal incontinence: sacral nerve stimulation (SNS) and percutaneous tibial nerve stimulation (PTNS). Surg Today 2014; 44:2124-30. [PMID: 24792064 DOI: 10.1007/s00595-014-0898-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 11/20/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND PURPOSE Two types of neuromodulation are currently practised for the treatment of fecal incontinence (FI): sacral nerve stimulation (SNS) and percutaneous tibial nerve stimulation (PTNS). This study compares these therapies, as no data exist to prospectively assess their relative efficacy and costs. METHODS The subjects of this study were two distinct cohorts undergoing SNS (between 2003 and 2008) or PTNS (2008-onwards) for FI. Clinical outcomes assessed at 3 months included incontinence scores and the number of weekly incontinence episodes. The direct medical costs for each procedure were calculated from the audited expenditure of our unit. RESULTS Thirty-seven patients (94.6 % women) underwent permanent SNS and 146 (87.7 % women) underwent PTNS. The mean pre-treatment incontinence score (± SD) was greater in the SNS cohort (14 ± 4 vs. 12 ± 4) and the mean post-treatment incontinence scores were similar for the two therapies (9 ± 5 vs. 10 ± 4), with a greater effect size evident in the SNS patients. In a 'pseudo case-control' analysis with 37 "matched" patients, the effect of both treatments was similar. The cost of treating a patient for 1 year was £ 11,374 ($ 18,223) for permanent SNS vs. £ 1740 ($ 2784) for PTNS. CONCLUSION Given the lesser cost and invasive nature of PTNS, where both techniques are available, a trial of PTNS could be considered for all patients.
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Affiliation(s)
- Alexander Hotouras
- Academic Surgical Unit, National Centre for Bowel Research and Surgical Innovation, Barts Health NHS Trust, London, UK,
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Abstract
Faecal incontinence is a common condition and is associated with considerable morbidity and economic cost. The majority of patients are managed with conservative interventions. However, for those patients with severe or refractory incontinence, surgical treatment might be required. Over the past 20 years, numerous developments have been made in the surgical therapies available to treat such patients. These surgical therapies can be classified as techniques of neuromodulation, neosphincter creation (muscle or artificial) and injection therapy. Techniques of neuromodulation, particularly sacral nerve stimulation, have transformed the management of these patients with a minimally invasive procedure that offers good results and low morbidity. By contrast, neosphincter procedures are characterized by being more invasive and associated with considerable morbidity, although some patients will experience substantial improvements in their continence. Injection of bulking agents into the anal canal can improve symptoms and quality of life in patients with mild-to-moderate incontinence, and the use of autologous myoblasts might be a future therapy. Further research and development is required not only in terms of the devices and procedures, but also to identify which patients are likely to benefit most from such interventions.
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Zbar AP. Sacral neuromodulation and peripheral nerve stimulation in patients with anal incontinence: an overview of techniques, complications and troubleshooting. Gastroenterol Rep (Oxf) 2014; 2:112-20. [PMID: 24759349 PMCID: PMC4020133 DOI: 10.1093/gastro/gou015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Sacral neuromodulation (SNM) therapy has revolutionized the management of many forms of anal incontinence, with an expanded use and a medium-term efficacy of 75% overall. This review discusses the technique of SNM therapy, along with its complications and troubleshooting and a discussion of the early data pertaining to peripheral posterior tibial nerve stimulation in incontinent patients. Future work needs to define the predictive factors for neurostimulatory success, along with the likely mechanisms of action of their therapeutic action.
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Affiliation(s)
- Andrew P Zbar
- Department of Surgery and Transplantation, Chaim Sheba Medical Center, Ramat Gan, Israel and Assia Medical Colorectal Group Assuta Private Hospital, Tel Aviv, Israel
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de la Portilla F, Laporte M, Maestre MV, Díaz-Pavón JM, Gollonet JL, Palacios C, Vázquez-Monchul JM, García-Cabrera AM, Jiménez-Rodríguez RM, Sánchez Gil JM. Percutaneous neuromodulation of the posterior tibial nerve for the treatment of faecal incontinence - mid-term results: is retreatment required? Colorectal Dis 2014; 16:304-10. [PMID: 24617790 DOI: 10.1111/codi.12539] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2013] [Revised: 11/02/2013] [Accepted: 11/06/2013] [Indexed: 02/08/2023]
Abstract
AIM Posterior tibial nerve stimulation (PTNS) has emerged in recent years as a therapy for faecal incontinence. Its long-term effectiveness is yet to be established, along with what the form of retreatment should be in the event of loss of effectiveness. The present study aimed to establish the mid-term results to identify the proportion of patients who may need further treatment, and if so when. METHOD A prospective study including 30 patients was conducted at an academic hospital. The patients underwent 12 weekly outpatient treatment sessions, each lasting 30 min (first PTNS phase). Neuromodulation was discontinued in those patients who did not have a 40% decrease in their pretreatment Wexner score. Patients having a better than 40% response were offered another 12-week course of complete treatment (second PTNS phase), following which they received no further PTNS treatment (phase without PTNS) but were assessed at 6 months and 2 years. RESULTS All patients finished the first phase and 22/30 patients continued to the second phase. During this phase 11 patients showed an improved Wexner score (baseline/first phase/second phase: 14.3 ± 4.2 vs 9.9 ± 5.4 vs 6.8 ± 5.4). After a 6-month period without any treatment, the score was still improved in 11/30 patients (9.1 ± 6.2). At 2 years there was improvement in 16/30 patients (8.8 ± 7.1). There was a significant improvement in three variables of the quality of life questionnaire: lifestyle, coping behaviour and embarrassment. CONCLUSION The response to first and second phase PTNS was maintained for up to 2 years. Retreatment was not required in about half of patients, even when they had finished the treatment 6 months or 2 years previously.
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Affiliation(s)
- F de la Portilla
- Unidad de Gestión Clínica de Cirugía General y del Aparato Digestivo, Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Seville, Spain
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Kaiser AM, Orangio GR, Zutshi M, Alva S, Hull TL, Marcello PW, Margolin DA, Rafferty JF, Buie WD, Wexner SD. Current status: new technologies for the treatment of patients with fecal incontinence. Surg Endosc 2014; 28:2277-301. [PMID: 24609699 DOI: 10.1007/s00464-014-3464-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 01/28/2014] [Indexed: 12/13/2022]
Abstract
Fecal incontinence is a frequent and debilitating condition that may result from a multitude of different causes. Treatment is often challenging and needs to be individualized. During the last several years, new technologies have been developed, and others are emerging from clinical trials to commercialization. Although their specific roles in the management of fecal incontinence have not yet been completely defined, surgeons have access to them and patients may request them. The purpose of this project is to put into perspective, for both the patient and the practitioner, the relative positions of new and emerging technologies in order to propose a treatment algorithm.
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Affiliation(s)
- Andreas M Kaiser
- Department of Colorectal Surgery, Keck School of Medicine, University of Southern California, 1441 Eastlake Avenue, Suite 7418, Los Angeles, CA, 90033, USA,
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Horrocks EJ, Thin N, Thaha MA, Taylor SJC, Norton C, Knowles CH. Systematic review of tibial nerve stimulation to treat faecal incontinence. Br J Surg 2014; 101:457-68. [DOI: 10.1002/bjs.9391] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2013] [Indexed: 12/27/2022]
Abstract
Abstract
Background
Two forms of tibial nerve stimulation are used to treat faecal incontinence (FI): percutaneous (PTNS) and transcutaneous (TTNS) tibial nerve stimulation. This article critically appraises the literature on both procedures.
Methods
A systematic review was performed adhering to the PRISMA framework. A comprehensive literature search was conducted, with systematic methodological quality assessment and data extraction. Summary measures for individual outcome variables are reported.
Results
Twelve articles met eligibility criteria; six related to PTNS, five to TTNS, and one to both procedures. These included ten case series and two randomized clinical trials (RCTs). Case series were evaluated using the National Institute for Health and Care Excellence quality assessment for case series, scoring 3–6 of 8. RCTs were evaluated using the Jadad score, scoring 4 of a possible 5 marks, and the Cochrane Collaboration bias assessment tool. From one RCT and case series reports, the success rate of PTNS, based on the proportion of patients who achieved a reduction in weekly FI episodes of at least 50 per cent, was 63–82 per cent, and that of TTNS was 0–45 per cent. In an RCT of TTNSversus sham, no patient had a reduction in weekly FI episodes of 50 per cent or more, whereas in an RCT of PTNSversus TTNSversus sham, 82 per cent of patients undergoing PTNS, 45 per cent of those having TTNS, and 13 per cent of patients in the sham group had treatment success.
Conclusion
PTNS and TTNS result in significant improvements in some outcome measures; however, TTNS was not superior to sham stimulation in a large, adequately powered, RCT. As no adequate RCT of PTNSversus sham has been conducted, conclusions cannot be drawn regarding this treatment.
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Affiliation(s)
- E J Horrocks
- National Centre for Bowel Research and Surgical Innovation and Queen Mary University London, UK
| | - N Thin
- National Centre for Bowel Research and Surgical Innovation and Queen Mary University London, UK
| | - M A Thaha
- National Centre for Bowel Research and Surgical Innovation and Queen Mary University London, UK
| | - S J C Taylor
- Centre for Primary Care and Public Health, Blizard Institute, Queen Mary University London, UK
| | - C Norton
- Florence Nightingale School of Nursing and Midwifery, King's College London, London, UK
| | - C H Knowles
- National Centre for Bowel Research and Surgical Innovation and Queen Mary University London, UK
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George AT, Maitra RK, Maxwell-Armstrong C. Posterior tibial nerve stimulation for fecal incontinence: Where are we? World J Gastroenterol 2013; 19:9139-9145. [PMID: 24409042 PMCID: PMC3882388 DOI: 10.3748/wjg.v19.i48.9139] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 10/23/2013] [Accepted: 11/05/2013] [Indexed: 02/06/2023] Open
Abstract
Neurostimulation remains the mainstay of treatment for patients with faecal incontinence who fails to respond to available conservative measures. Sacral nerve stimulation (SNS) is the main form of neurostimulation that is in use today. Posterior tibial nerve stimulation (PTNS) - both the percutaneous and the transcutaneous routes - remains a relatively new entry in neurostimulation. Though in its infancy, PTNS holds promise to be an effective, patient friendly, safe and cheap treatment. However, presently PTNS only appears to have a minor role with SNS having the limelight in treating patients with faecal incontinence. This seems to have arisen as the strong, uniform and evidence based data on SNS remains to have been unchallenged yet by the weak, disjointed and unsupported evidence for both percutaneous and transcutaneous PTNS. The use of PTNS is slowly gaining acceptance. However, several questions remain unanswered in the delivery of PTNS. These have raised dilemmas which as long as they remain unsolved can considerably weaken the argument that PTNS could offer a viable alternative to SNS. This paper reviews available information on PTNS and focuses on these dilemmas in the light of existing evidence.
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Thomas GP, Dudding TC, Bradshaw E, Nicholls RJ, Vaizey CJ. A pilot study to compare daily with twice weekly transcutaneous posterior tibial nerve stimulation for faecal incontinence. Colorectal Dis 2013; 15:1504-9. [PMID: 24118972 DOI: 10.1111/codi.12428] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Accepted: 07/22/2013] [Indexed: 12/12/2022]
Abstract
AIM Posterior tibial nerve stimulation (PTNS) has been shown to improve faecal incontinence in the short term. The optimal treatment regimen is unclear with wide variations in protocol reported in the literature. The study aimed to assess two different regimens of transcutaneous PTNS and to establish whether increasing the frequency of stimulation increases the effectiveness. METHOD Thirty patients were randomized to receive once daily or twice weekly PTNS for a 6-week period. The treatment was carried out by the patient at home after instruction. The primary investigator was blinded to the patient allocation until the study had ended, at which point the symptoms were assessed. No further stimulation was given after 6 weeks and the patients were followed until their symptoms returned to the pre-stimulation state (baseline). The primary outcome measure was a change in the frequency of incontinent episodes. RESULTS Three patients in the daily group and none in the twice weekly group achieved complete continence. Only patients from the daily group showed a significant reduction in median (interquartile range) incontinent episodes per week from 5 (11.13) to 3.5 (4.31) (P = 0.025). There was no significant change in the frequency of defaecation nor in the ability to defer defaecation. Patients in the daily group experienced a significant improvement in the domains of lifestyle [2.2 (1.7) to 2.6 (1.65), P = 0.04] and embarrassment [1.7 (0.85) to 2.15 (0.4), P = 0.04] on the Rockwood Fecal Incontinence Quality of Life assessment. No adverse events were reported. CONCLUSION Transcutaneous PTNS can safely be used by the patient at home. Daily treatment may be more effective than twice weekly treatment. Larger studies are needed to investigate this further.
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Affiliation(s)
- G P Thomas
- Sir Alan Parks Department of Physiology, St Mark's Hospital and Academic Institute, Harrow, UK
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Thin NN, Horrocks EJ, Hotouras A, Palit S, Thaha MA, Chan CLH, Matzel KE, Knowles CH. Systematic review of the clinical effectiveness of neuromodulation in the treatment of faecal incontinence. Br J Surg 2013; 100:1430-47. [PMID: 24037562 DOI: 10.1002/bjs.9226] [Citation(s) in RCA: 133] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND Over the past 18 years neuromodulation therapies have gained support as treatments for faecal incontinence (FI); sacral nerve stimulation (SNS) is the most established of these. A systematic review was performed of current evidence regarding the clinical effectiveness of neuromodulation treatments for FI. METHODS The review adhered to the PRISMA framework. A comprehensive search of the literature included PubMed, MEDLINE, Embase and Evidence-Based Medicine Reviews. Methodological quality assessment and data extraction were completed in a systematic fashion. RESULTS For SNS, 321 citations were identified initially, of which 61 studies were eligible for inclusion. Of studies on other neuromodulation techniques, 11 were eligible for review: seven on percutaneous tibial nerve stimulation (PTNS) and four on transcutaneous tibial nerve stimulation (TTNS). On intention-to-treat, the median (range) success rates for SNS were 63 (33-66), 58 (52-81) and 54 (50-58) per cent in the short, medium and long terms respectively. The success rate for PTNS was 59 per cent at the longest reported follow-up of 12 months. SNS, PTNS and TTNS techniques also resulted in improvements in Cleveland Clinic Incontinence Score and quality-of-life measures. Despite significant use of neuromodulation in treatment of FI, there is still no consensus on outcome reporting in terms of measures used, aetiologies assessed, length of follow-up or assessment standards. CONCLUSION Emerging data for SNS suggest maintenance of its initial therapeutic effect into the long term. The clinical effectiveness of PTNS is comparable to that of SNS at 12 months, although there is no evidence to support its continued effectiveness after this period. PTNS may be a useful treatment before SNS. The clinical effectiveness of TTNS is still uncertain owing to the paucity of available evidence. A consensus to standardize the use of outcome measures is recommended in order that further reports can be compared meaningfully.
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Affiliation(s)
- N N Thin
- National Centre for Bowel Research and Surgical Innovation, London, UK
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Abstract
BACKGROUND Unilateral posterior tibial nerve stimulation has been shown to improve fecal incontinence in the short term. Posterior tibial nerve stimulation is believed to work by stimulation of the ascending afferent spinal pathways. Bilateral stimulation may activate more of these pathways. This may lead to an improved therapeutic effect. OBJECTIVE The aim of this study was to assess the efficacy of bilateral transcutaneous posterior tibial nerve stimulation for fecal incontinence. DESIGN This was a single-group pilot prospective study. SETTING The study was conducted from June 2012 to September 2012 at the authors' institution. PATIENTS Twenty patients with fecal incontinence were recruited consecutively. Conservative therapy had failed to improve the fecal incontinence in all 20 patients. INTERVENTION All patients received 30 minutes of daily bilateral stimulation for 6 weeks. The bilateral stimulation was administered by each patient at home. No further stimulation was given after 6 weeks, and the patients were followed up until their symptoms returned to the prestimulation state (baseline). MAIN OUTCOME MEASURE The primary outcome measure was a change in the frequency of incontinent episodes per week. RESULTS Seventeen patients completed 6 weeks of treatment. Two patients achieved complete continence. Ten (59%) achieved a ≥50% reduction in frequency of incontinent episodes. Overall, there was a significant reduction in median (interquartile range) frequency of incontinent episodes per week of 6 (8.25) to 2 (7.25) (p = 0.03). There was a significant improvement in the ability to defer defecation from 3 (4) to 5 (8) minutes (p = 0.03). There was no change in the St Mark's incontinence score. One domain of the Rockwood fecal incontinence quality-of-life score and of the Medical Outcomes Study Short Form 36 score improved significantly. LIMITATIONS This study was limited by its small size and its lack of blinding and control. CONCLUSIONS Bilateral transcutaneous posterior tibial nerve stimulation appears to be a cheap and effective treatment for fecal incontinence. It can easily be used by the patient at home.
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