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Koifman E, Armoni M, Gorelik Y, Harbi A, Streltsin Y, Duek SD, Brun R, Mazor Y. Long term persistence and risk factors for anorectal symptoms following low anterior resection for rectal cancer. BMC Gastroenterol 2024; 24:31. [PMID: 38216868 PMCID: PMC10787434 DOI: 10.1186/s12876-023-03112-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 12/28/2023] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND Rectal cancer is commonly treated by chemoradiation therapy, followed by the low anterior resection anal sphincter-preserving surgery, with a temporary protecting ileostomy. After reversal of the stoma a condition known as low anterior resection syndrome (LARS) can occur characterized by a combination of symptoms such as urgent bowel movements, lack of control over bowel movements, and difficulty fully emptying the bowels. These symptoms have a significant negative impact on the quality of life for individuals who have survived the cancer. Currently, there is limited available data regarding the presence, risk factors, and effects of treatment for these symptoms during long-term follow-up. AIMS To evaluate long term outcomes of low anterior resection surgery and its correlation to baseline anorectal manometry (ARM) parameters and physiotherapy with anorectal biofeedback (BF) treatment. METHODS One hundred fifteen patients (74 males, age 63 ± 11) who underwent low anterior resection surgery for rectal cancer were included in the study. Following surgery, patients were managed by surgical and oncologic team, with more symptomatic LARS patients referred for further evaluation and treatment by gastroenterologists. At follow up, patients were contacted and offered participation in a long term follow up by answering symptom severity and quality of life (QOL) questionnaires. RESULTS 80 (70%) patients agreed to participate in the long term follow up study (median 4 years from stoma reversal, range 1-8). Mean time from surgery to stoma closure was 6 ± 4 months. At long term follow up, mean LARS score was 30 (SD 11), with 55 (69%) patients classified as major LARS (score > 30). Presence of major LARS was associated with longer time from surgery to stoma reversal (6.8 vs. 4.8 months; p = 0.03) and with adjuvant chemotherapy (38% vs. 8%; p = 0.01). Patients initially referred for ARM and BF were more likely to suffer from major LARS at long term follow up (64% vs. 16%, p < 0.001). In the subgroup of patients who underwent perioperative ARM (n = 36), higher maximal squeeze pressure, higher maximal incremental squeeze pressure and higher rectal pressure on push were all associated with better long-term outcomes of QOL parameters (p < 0.05 for all). 21(54%) of patients referred to ARM were treated with BF, but long term outcomes for these patients were not different from those who did not perform BF. CONCLUSIONS A significant number of patients continue to experience severe symptoms and a decline in their quality of life even 4 years after undergoing low anterior resection surgery. Prolonged time until stoma reversal and adjuvant chemotherapy emerged as the primary risk factors for a negative prognosis. It is important to note that referring patients for anorectal physiology testing alone tended to predict poorer long-term outcomes, indicating the presence of selection bias. However, certain measurable manometric parameters could potentially aid in identifying patients who are at a higher risk of experiencing unfavorable functional outcomes. There is a critical need to enhance current treatment options for this patient group.
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Affiliation(s)
- E Koifman
- Rambam Health Care Campus, Department of Gastroenterology, Haifa, Israel.
| | - M Armoni
- Rambam Health Care Campus, Department of Gastroenterology, Haifa, Israel
| | - Y Gorelik
- Rambam Health Care Campus, Department of Gastroenterology, Haifa, Israel
| | - A Harbi
- Rambam Health Care Campus, Department of General Surgery, Haifa, Israel
| | - Y Streltsin
- Rambam Health Care Campus, Department of Gastroenterology, Haifa, Israel
| | - S D Duek
- Rambam Health Care Campus, Department of General Surgery, Haifa, Israel
| | - R Brun
- Rambam Health Care Campus, Department of Gastroenterology, Haifa, Israel
| | - Y Mazor
- Rambam Health Care Campus, Department of Gastroenterology, Haifa, Israel
- Department of Medical Neurobiology, The Hebrew University of Jerusalem, Jerusalem, Israel
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Aloysius MM, Korsten MA, Radulovic M, Singh K, Lyons BL, Cummings T, Hobson J, Kahal S, Spungen AM, Bauman WA. Lack of improvement in anorectal manometry parameters after implementation of a pelvic floor/anal sphincter biofeedback in persons with motor-incomplete spinal cord injury. Neurogastroenterol Motil 2023; 35:e14667. [PMID: 37743783 DOI: 10.1111/nmo.14667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 07/30/2023] [Accepted: 08/21/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Effect of biofeedback on improving anorectal manometric parameters in incomplete spinal cord injury is unknown. A short-term biofeedback program investigated any effect on anorectal manometric parameters without correlation to bowel symptoms. METHODS This prospective uncontrolled interventional study comprised three study subject groups, Group 1: sensory/motor-complete American Spinal Injury Association Impairment Scale (AIS) A SCI (n = 13); Group 2 (biofeedback group): sensory incomplete AIS B SCI (n = 17) (n = 3), and motor-incomplete AIS C SCI (n = 8), and AIS D SCI (n = 6); and Group 3: able-bodied (AB) controls (n = 12). High-resolution anorectal manometry (HR-ARM) was applied to establish baseline characteristics in all subjects for anorectal pressure, volume, length of pressure zones, and duration of sphincter squeeze pressure. SCI participants with motor-incomplete SCI were enrolled in pelvic floor/anal sphincter bowel biofeedback training (2 × 6-week training periods comprised of two training sessions per week for 30-45 min per session). HR-ARM was also performed after each of the 6-week periods of biofeedback training. RESULTS Compared to motor-complete or motor-incomplete SCI participants, AB subjects had higher mean intra-rectal pressure, maximal sphincteric pressure, residual anal pressure, recto-anal pressure gradient, and duration of squeeze (p < 0.05 for each of the endpoints). No significant difference was evident at baseline between the motor-complete and motor-incomplete SCI groups. In motor-incomplete SCI subjects, the pelvic floor/anal sphincter biofeedback protocol failed to improve HR-ARM parameters. CONCLUSION Biofeedback training program did not improve anal manometric parameters in subjects with motor-incomplete or sensory-incomplete SCI. Biofeedback did not change physiology, and its effects on symptoms are unknown. INFERENCES Utility of biofeedback is limited in patients with incomplete spinal cord injury in terms of improving HR-ARM parameters.
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Affiliation(s)
- Mark M Aloysius
- Department of Medicine, The Wright Center for Graduate Medical Education, Scranton, Pennsylvania, USA
- Department of Medicine, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Mark A Korsten
- National Center for Medical Consequences of Spinal Cord Injury, James J Peters VA Medical Center, Bronx, New York, USA
- Medical Service, James J Peters VA Medical Center, Bronx, New York, USA
- Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Rehabilitation Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Miroslav Radulovic
- National Center for Medical Consequences of Spinal Cord Injury, James J Peters VA Medical Center, Bronx, New York, USA
- Medical Service, James J Peters VA Medical Center, Bronx, New York, USA
- Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Rehabilitation Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kamaldeep Singh
- Department of Medicine, College of Medicine, Tucson, Arizona, USA
| | - Brian L Lyons
- National Center for Medical Consequences of Spinal Cord Injury, James J Peters VA Medical Center, Bronx, New York, USA
| | | | - Joshua Hobson
- National Center for Medical Consequences of Spinal Cord Injury, James J Peters VA Medical Center, Bronx, New York, USA
| | - Sandeep Kahal
- Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ann M Spungen
- National Center for Medical Consequences of Spinal Cord Injury, James J Peters VA Medical Center, Bronx, New York, USA
- Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Rehabilitation Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - William A Bauman
- National Center for Medical Consequences of Spinal Cord Injury, James J Peters VA Medical Center, Bronx, New York, USA
- Medical Service, James J Peters VA Medical Center, Bronx, New York, USA
- Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Rehabilitation Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Remes-Troche JM, Coss-Adame E, García-Zermeño KR, Gómez-Escudero O, Amieva-Balmori M, Gómez-Castaños PC, Charúa-Guindic L, Icaza-Chávez ME, López-Colombo A, Morel-Cerda EC, Pérez Y López N, Rodríguez-Leal MC, Salgado-Nesme N, Sánchez-Avila MT, Valdovinos-García LR, Vergara-Fernández O, Villar-Chávez AS. The Mexican consensus on fecal incontinence. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2023; 88:404-428. [PMID: 38097437 DOI: 10.1016/j.rgmxen.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 08/08/2023] [Indexed: 01/01/2024]
Abstract
Fecal incontinence is the involuntary passage or the incapacity to control the release of fecal matter through the anus. It is a condition that significantly impairs quality of life in those that suffer from it, given that it affects body image, self-esteem, and interferes with everyday activities, in turn, favoring social isolation. There are no guidelines or consensus in Mexico on the topic, and so the Asociación Mexicana de Gastroenterología brought together a multidisciplinary group (gastroenterologists, neurogastroenterologists, and surgeons) to carry out the «Mexican consensus on fecal incontinence» and establish useful recommendations for the medical community. The present document presents the formulated recommendations in 35 statements. Fecal incontinence is known to be a frequent entity whose incidence increases as individuals age, but one that is under-recognized. The pathophysiology of incontinence is complex and multifactorial, and in most cases, there is more than one associated risk factor. Even though there is no diagnostic gold standard, the combination of tests that evaluate structure (endoanal ultrasound) and function (anorectal manometry) should be recommended in all cases. Treatment should also be multidisciplinary and general measures and drugs (lidamidine, loperamide) are recommended, as well as non-pharmacologic interventions, such as biofeedback therapy, in selected cases. Likewise, surgical treatment should be offered to selected patients and performed by experts.
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Affiliation(s)
- J M Remes-Troche
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Mexico.
| | - E Coss-Adame
- Departamento de Gastroenterología y Laboratorio de Motilidad Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Mexico City, Mexico
| | - K R García-Zermeño
- Gastroenterología y Motilidad Digestiva, CIGMA, Boca del Río, Veracruz, Mexico
| | - O Gómez-Escudero
- Clínica de Gastroenterología, Endoscopía Digestiva y Motilidad Gastrointestinal, Hospital Ángeles de Puebla, Puebla, Mexico
| | - M Amieva-Balmori
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Mexico
| | - P C Gómez-Castaños
- Centro de Investigación y Docencia en Ciencias de la Salud, Universidad Autónoma de Sinaloa, Culiacán, Sinaloa, Mexico
| | - L Charúa-Guindic
- Práctica privada, Coloproctología del Hospital Ángeles Lomas, Mexico City, Mexico
| | - M E Icaza-Chávez
- Hospital Christus Muguerza Faro del Mayab, Mérida, Yucatán, Mexico
| | - A López-Colombo
- UMAE Hospital de Especialidades, Centro Médico Nacional Manuel Ávila Camacho, IMSS Puebla, Puebla, Mexico
| | - E C Morel-Cerda
- Laboratorio de Motilidad Gastrointestinal, Hospital Civil Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | | | - M C Rodríguez-Leal
- Hospital Ángeles Valle Oriente, IMSS UMAE 25, Monterrey, Nuevo León, Mexico
| | - N Salgado-Nesme
- Departamento de Cirugía, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Mexico City,Mexico
| | - M T Sánchez-Avila
- Escuela de Medicina y Ciencias de la Salud, Tecnológico de Monterrey, Monterrey, Nuevo León, Mexico
| | - L R Valdovinos-García
- Laboratorio de Motilidad Gastrointestinal Fundación Clínica Médica Sur, Mexico City, Mexico
| | - O Vergara-Fernández
- Departamento de Cirugía Colorrectal, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, Mexico
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Differences in Anorectal Manometry Values Among Women With Fecal Incontinence in a Racially, Ethnically, and Socioeconomically Diverse Population. UROGYNECOLOGY (HAGERSTOWN, MD.) 2023; 29:244-251. [PMID: 36735440 DOI: 10.1097/spv.0000000000001324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
IMPORTANCE Anorectal manometry (ARM) is a valuable diagnostic and therapeutic tool that can both aid in identifying mechanisms contributing to fecal incontinence (FI) and inform management strategies. Consensus on standard reference range values has not been established, and women of varying racial and ethnic backgrounds are not well-represented in the current literature. OBJECTIVE We aimed to compare ARM values between women of different racial and ethnic groups with FI. STUDY DESIGN We conducted a retrospective cross-sectional study of women with FI who underwent ARM at a tertiary health system in an urban underserved community between 2016 and 2021. Demographic information and ARM values were collected from the medical record. Socioeconomic status (SES) was represented by the percent of the population living below the poverty line according to zip code using U.S. census data. Anorectal manometry values were compared between racial and ethnic groups, and multivariable logistic regression was conducted to control for patient characteristics. RESULTS Fifty-eight women were included in the analysis: 33% Hispanic, 22% Black, and 45% White. Hispanic and Black women had higher body mass index and higher rates of diabetes and loose stools and were of significantly lower SES compared with White women. Black and Hispanic women had significantly lower thresholds for volume at first sensation and higher mean anal squeeze pressure. Differences were maintained after controlling for body mass index, diabetes, SES, and diarrhea (P = 0.03 and P = 0.01, respectively). Other ARM values were not significantly different between groups. CONCLUSIONS Racial and ethnic differences in ARM values among women with FI exist. Further studies are needed to determine whether these differences have an impact on symptom severity, treatment selection and outcomes, and patient satisfaction.
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Sharma M, Lowry AC, Rao SS, Whitehead WE, Szarka LA, Hamilton FA, Bharucha AE. A multicenter study of anorectal pressures and rectal sensation measured with portable manometry in healthy women and men. Neurogastroenterol Motil 2021; 33:e14067. [PMID: 33462889 PMCID: PMC8169521 DOI: 10.1111/nmo.14067] [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] [Received: 07/23/2020] [Revised: 10/22/2020] [Accepted: 12/01/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The equipment and methods for performing anorectal manometry and biofeedback therapy are different and not standardized. Normal values are influenced by age and sex. Our aims were to generate reference values, examine effects of gender and age, and compare anorectal pressures measured with diagnostic and biofeedback catheters and a portable manometry system. METHODS In this multicenter study, anorectal pressures at rest, during squeeze, and evacuation were measured with diagnostic and biofeedback catheters using Mcompass™ portable device in healthy subjects. Balloon expulsion time and rectal sensation were evaluated. The effects of age and gender were assessed. RESULTS The final dataset comprised 108 (74 women) of 124 participants with normal rectal balloon expulsion time (less than 60 s). During squeeze, anal resting pressure increased by approximately twofold in women and threefold in men. During evacuation, anal pressure exceeded rectal pressure in 87 participants (diagnostic catheter). The specific rectoanal pressures (e.g., resting pressure) were significantly correlated and not different between diagnostic and biofeedback catheters. With the diagnostic catheter, the anal squeeze pressure and rectal pressure during evacuation were greater in men than women (p ≤ 0.02). Among women, women aged 50 years and older had lower anal resting pressure; rectal pressure and the rectoanal gradient during evacuation were greater in older than younger women (p ≤ 0.01). CONCLUSIONS Anal and rectal pressures measured with diagnostic and biofeedback manometry catheters were correlated and not significantly different. Pressures were influenced by age and sex, providing reference values in men and women.
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Affiliation(s)
- Mayank Sharma
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Mn
| | - Ann C. Lowry
- Colon and Rectal Surgery Associates, Minneapolis, Mn
| | - Satish S. Rao
- Division of Gastroenterology, Augusta University, Augusta, Ga
| | - William E. Whitehead
- Center for Functional GI and Motility Disorders, University of North Carolina, Chapel Hill, NC
| | | | - Frank A. Hamilton
- National Institute of Digestive Diseases, Kidney, and Diabetes, Bethesda, MD
| | - Adil E. Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Mn
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Mazor Y, Prott G, Jones M, Ejova A, Kellow J, Malcom A. Factors Associated With Response to Anorectal Biofeedback Therapy in Patients With Fecal Incontinence. Clin Gastroenterol Hepatol 2021; 19:492-502.e5. [PMID: 32251788 DOI: 10.1016/j.cgh.2020.03.050] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 03/06/2020] [Accepted: 03/22/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Anorectal biofeedback (BF) is commonly used to treat patients with fecal incontinence (FI), but demand usually exceeds availability. It is therefore important to identify patients most likely to respond to BF treatment. We aimed to identify pre-treatment clinical or physiologic factors that might be used to predict completion and success of BF in women with FI. METHODS We analyzed data from 400 women with FI (mean age, 61 ± 14 y) undergoing instrumental BF in a tertiary care setting from 2003 through 2016. All patients completed questionnaires before BF, including Rome and the hospital anxiety and depression scale questionnaires. Histories of medication use, surgery, medical conditions, and bowel pattern were recorded, urge was assessed, and patients kept stool diaries. Before and after treatment (6 weekly sessions with a gastroenterologist-supervised nurse specialist, 4 involving instrumented anorectal biofeedback), patients were examined by a physician and fecal incontinence severity index and visual analogue scale scores were recorded. The main outcome measure was response to therapy, defined as improvement of 50% or more in weekly FI episodes at the end of BF compared with before BF. RESULTS The BF treatment was completed by 363 women (91%); of these, 62 had low baseline symptom frequency (no FI episodes in the 2 weeks before BF). Younger age was associated with failure to complete treatment. Of the 301 patients remaining, 202 patients (67%) had a response to therapy; among these women, urge FI was associated with response at end of BF, but not at follow up (6 months after therapy). Baseline severity of symptom scores and quality of life measures were associated with greater improvement in the same variable at the end of BF and after 6 months. Patients with low baseline symptom frequency improved in all secondary outcome measures, similar to patients with higher baseline symptom frequency. CONCLUSIONS In an analysis of 363 women with FI, approximately two-thirds had a response to BF treatment. Urge FI was the only baseline variable associated with response. Baseline severity of symptoms and quality of life measures were associated with greater improvement in the same variable, but not overall response. It is therefore a challenge to select treatment for patients with FI.
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Affiliation(s)
- Yoav Mazor
- Department of Gastroenterology, Royal North Shore Hospital, St Leonards, NSW; University of Sydney, Sydney, NSW.
| | - Gillian Prott
- Department of Gastroenterology, Royal North Shore Hospital, St Leonards, NSW
| | - Michael Jones
- Department of Psychology, Macquarie University, Sydney, NSW, Australia
| | - Anastasia Ejova
- Department of Psychology, Macquarie University, Sydney, NSW, Australia
| | - John Kellow
- Department of Gastroenterology, Royal North Shore Hospital, St Leonards, NSW; University of Sydney, Sydney, NSW
| | - Allison Malcom
- Department of Gastroenterology, Royal North Shore Hospital, St Leonards, NSW; University of Sydney, Sydney, NSW
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Nurse- and Pelvic Floor Physical Therapist-Led Bowel Training in Patients With Fecal Incontinence in a Tertiary Care Center. Gastroenterol Nurs 2021; 44:39-46. [PMID: 33538522 DOI: 10.1097/sga.0000000000000498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 10/07/2019] [Indexed: 11/25/2022] Open
Abstract
Little is known about nurse- and pelvic floor physical therapist-led bowel training in fecal incontinence after previous conservative management has been deemed unsatisfactory. The objective of this study was to evaluate combined nurse- and physical therapist-led bowel training sessions in a tertiary care center. This was a prospective, cross-sectional study. All patients with fecal incontinence between 2015 and 2016 with and without previous conservative management were included. Combined conservative treatment was defined as the use of stool-bulking agents (psyllium fibers) with or without antidiarrheal medication (loperamide) in combination with biofeedback or pelvic floor muscle training. Questionnaires regarding fecal incontinence (Vaizey incontinence score) and quality of life (Short Form Health Survey-36) were used. A decrease in the Vaizey incontinence score of 5 or more points was deemed to be clinically significant. Vaizey incontinence scores in all 50 patients decreased from 14.7 (SD = 4.5) to 9.9 (SD = 4.8) at follow-up (p < .001). Forty percent of patients reported an improvement in their Vaizey incontinence score (change of 5 or more points). Improvement was noted in those with and without previous treatment. Quality of life improved significantly. The limitation of the study includes lack of a standardized treatment protocol. Fecal incontinence reduced after nurse- and physical therapist-led bowel training sessions in patients with and without previous treatment, increasing their quality of life.
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Abstract
PURPOSE OF REVIEW To review the epidemiology, pathogenesis, clinical features, and management of primary constipation and fecal incontinence in the elderly. RECENT FINDINGS Among elderly people, 6.5%, 1.7%, and 1.1% have functional constipation, constipation-predominant IBS, and opioid-induced constipation. In elderly people, the number of colonic enteric neurons and smooth muscle functions is preserved; decreased cholinergic function with unopposed nitrergic relaxation may explain colonic motor dysfunction. Less physical activity or dietary fiber intake and postmenopausal hormonal therapy are risk factors for fecal incontinence in elderly people. Two thirds of patients with fecal incontinence respond to biofeedback therapy. Used in combination, loperamide and biofeedback therapy are more effective than placebo, education, and biofeedback therapy. Vaginal or anal insert devices are another option. In the elderly, constipation and fecal incontinence are common and often distressing symptoms that can often be managed by addressing bowel disturbances. Selected diagnostic tests, prescription medications, and, infrequently, surgical options should be considered when necessary.
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Affiliation(s)
- Brototo Deb
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street, Rochester, MN, 55905, USA
| | - David O Prichard
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street, Rochester, MN, 55905, USA
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street, Rochester, MN, 55905, USA.
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Abstract
Anorectal disorders encompass structural, neuromuscular, and functional disorders. They are common, often distressing, and in some cases debilitating, and significantly add to the health care burden. They present with multiple, overlapping symptoms that can often obscure the underlying pathology and can pose significant diagnostic and management dilemmas. A meticulous history and comprehensive digital rectal examination can provide clarity on the diagnosis, appropriate testing, and management of these conditions. Today, with the development of sophisticated diagnostic tools such as high-resolution and high-definition (3-D) anorectal manometry, 3-D anal ultrasonography, magnetic resonance defecography and imaging, and neurophysiological tests such as translumbosacral anorectal magnetic stimulation, it is possible to more accurately define and characterize the underlying structural and functional abnormalities. In this review, we present a succinct update on the latest knowledge with regards to the pathophysiology, diagnosis and management of anal fissure, hemorrhoids, rectal prolapse, intussusception, rectocele, solitary rectal ulcer syndrome, levator ani syndrome, dyssynergic defecation and fecal incontinence.
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Gupta A, Hobson DTG, Petro M, Al-Juburi A, Francis S, Abell TL. Can Baseline Electromyography Predict Response to Biofeedback for Anorectal Disorder? A Long-Term Follow-Up Study. Gastroenterology Res 2019; 12:252-255. [PMID: 31636775 PMCID: PMC6785285 DOI: 10.14740/gr1213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 08/22/2019] [Indexed: 11/11/2022] Open
Abstract
Background Biofeedback has been recommended for the treatment of anorectal disorders, especially constipation and fecal incontinence (FI). The objective of this study was to assess the long-term efficacy of biofeedback and evaluate baseline electromyography (EMG) as a predictor for maintenance of long-term improvement. Methods A retrospective chart review was performed on randomly selected patients who underwent biofeedback between the years 1990 and 2000. Clinical characteristics, including EMG values at baseline (resting and contraction) as well as EMG after exercises, were collected. Patients were contacted and were classified as “improved” if they had self-reported symptomatic improvement and “not-improved” if their symptoms were unchanged or worsened. Results A total of 41 subjects were included. Majority (85.4%) were female, the mean age was 48.95 ± 15.46 (range 22 - 77 years) and the median follow-up was 4 years (range 4 - 5 years). Constipation was the primary indication for biofeedback in 27/41 (65.9%), FI in 9/41 (22%) and “other” in 5/41 (12.1%). Within constipation, 55.6% reported long-term improvement as compared to 66.7% of FI and 80% of the other patients. There was borderline difference in the baseline EMG (3.11 ± 1.85 µV, improved, and 7.41 ± 11.01 µV, not improved, P = 0.06) but no significant difference in post-exercise resting (3.13 ± 3.21 µV, improved, and 4.28 ± 3.63 µV, not improved, P = 0.33) and contraction EMG between the two groups. Conclusions Biofeedback is an important treatment tool in anorectal disorders. Over 50% of our subjects maintained their improvement 4 - 5 years after completing biofeedback therapy. A lower resting baseline EMG showed a trend of association with improvement in the long term.
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Affiliation(s)
- Ankita Gupta
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, University of Louisville School of Medicine, Louisville, KY, USA
| | - Deslyn T G Hobson
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, University of Louisville School of Medicine, Louisville, KY, USA
| | | | - Amar Al-Juburi
- Division of Gastroenterology and Hepatology, Davis School of Medicine, University of California, Sacremento, CA, USA
| | - Sean Francis
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, University of Louisville School of Medicine, Louisville, KY, USA
| | - Thomas L Abell
- Division of Gastroenterology, Hepatology and Nutrition, University of Louisville School of Medicine, Louisville, KY, USA
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Chavez MR, Chase A, Clark CE, Turner J. Sacral Nerve Stimulator for the Treatment of Nocturnal Fecal Incontinence. Am Surg 2019. [DOI: 10.1177/000313481908500716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Mary Rebecca Chavez
- Division of Colon and Rectal Surgery Department of Surgery Morehouse School of Medicine Atlanta, Georgia
| | - Ayana Chase
- Division of Colon and Rectal Surgery Department of Surgery Morehouse School of Medicine Atlanta, Georgia
| | - Clarence E. Clark
- Division of Colon and Rectal Surgery Department of Surgery Morehouse School of Medicine Atlanta, Georgia
| | - Jacquelyn Turner
- Division of Colon and Rectal Surgery Department of Surgery Morehouse School of Medicine Atlanta, Georgia
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Abstract
PURPOSE OF REVIEW Biofeedback therapy (BFT) is effective for managing pelvic floor disorders (i.e., defecatory disorders and fecal incontinence). However, even in controlled clinical trials, only approximately 60% of patients with defecatory disorders experienced long-term improvement. The review serves to update practitioners on recent advances and to identify practical obstacles to providing biofeedback therapy. RECENT FINDINGS The efficacy and safety of biofeedback therapy have been evaluated in defecatory disorders, fecal incontinence, and levator ani syndrome. Recent studies looked at outcomes in specific patient sub-populations and predictors of a response to biofeedback therapy. Biofeedback therapy is effective for managing defecatory disorders, fecal incontinence, and levator ani syndrome. Patients who have a lower bowel satisfaction score and use digital maneuvers fare better. Biofeedback therapy is recommended for patients with fecal incontinence who do not respond to conservative management. A subset of patients with levator ani syndrome who have dyssynergic defecation are more likely to respond to biofeedback therapy.
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Mazor Y, Kellow JE, Prott GM, Jones MP, Malcolm A. Anorectal biofeedback: an effective therapy, but can we shorten the course to improve access to treatment? Therap Adv Gastroenterol 2019; 12:1756284819836072. [PMID: 30915166 PMCID: PMC6429655 DOI: 10.1177/1756284819836072] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 01/24/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Instrumented anorectal biofeedback (BF) improves symptoms and quality of life in patients with faecal incontinence and defecation disorder-associated chronic constipation. However, demand for BF greatly outweighs availability, so refinement of the BF protocol, in terms of the time and resources required, is of importance. Our aim was to evaluate the outcomes of an abbreviated BF protocol in patients with defecation disorder-associated chronic constipation and/or faecal incontinence compared to standard BF. METHODS Data were collected from consecutive patients (n = 31; age 54 ± 15; 29 females; 61% functional constipation) undergoing an intentionally abbreviated BF protocol, and compared in a 1:2 ratio with 62 age, gender and functional anorectal disorder-matched control patients undergoing a standard BF. Outcomes included change in symptoms, physiology, patient satisfaction and quality of life. RESULTS On intention to treat, patients in both protocols showed significant improvement in symptom scores and the magnitude did not differ between groups. Impact on quality of life, satisfaction and control over bowel movements improved in both protocols, but satisfaction improved to a greater extent in the standard BF protocol (p = 0.009). Physiological parameters were unchanged after BF apart from improvement in rectal sensation in the standard BF group compared to abbreviated BF (p ⩽ 0.002). CONCLUSIONS Abbreviated anorectal BF offered to patients travelling from far away was not different to a standard BF in providing substantial, at least short term, improvements in symptoms of constipation and faecal incontinence, quality of life and feeling of control over bowel movements. Refinement of the standard BF protocol according to individual patient phenotypes and desired outcomes warrants further study in order to maximize efficacy and improve access for patients.
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Affiliation(s)
- Yoav Mazor
- Royal North Shore Hospital, Reserve Road, St. Leonards, NSW, 2067, Australia University of Sydney, Sydney, NSW, Australia
| | - John E. Kellow
- Gastroenterology Department, Royal North Shore Hospital, St. Leonards, NSW, Australia University of Sydney, Sydney, NSW, Australia
| | - Gillian M. Prott
- Gastroenterology Department, Royal North Shore Hospital, St. Leonards, NSW, Australia
| | - Michael P. Jones
- Psychology Department, Macquarie University, Sydney, NSW, Australia
| | - Allison Malcolm
- Gastroenterology Department, Royal North Shore Hospital, St. Leonards, NSW, Australia University of Sydney, Sydney, NSW, Australia
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Brochard C, Peyronnet B, Hascoet J, Olivier R, Manunta A, Jezequel M, Alimi Q, Ropert A, Neunlist M, Bouguen G, Siproudhis L. Defecation disorders in Spina Bifida: Realistic goals and best therapeutic approaches. Neurourol Urodyn 2018; 38:719-725. [PMID: 30575995 DOI: 10.1002/nau.23904] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 09/23/2018] [Indexed: 01/06/2023]
Abstract
AIMS Spina Bifida (SB) is a rare congenital condition that frequently impairs the neurological control of both fecal continence and defecation. Several therapeutic strategies have been proposed but impact assessment is lacking. Our objectives were to quantify the symptomatic improvement and to determine the optimal strategy in this rare condition where randomized controlled trials are difficult to conduct. METHODS Data were extracted from a prospective database. The present analysis focused on patients having undergone at least two gastroenterological assessments. A standardized therapeutic approach was used from the first visit. Improvement was quantified by the variation of quantified symptomatic scores. RESULTS The data of of 57 adults with SB (gender F/M: 30/27 [52.6/47.4%]; mean age: 33.8 [18.5] years) were extracted. After a mean follow-up of 46 months, 23/57 patients (40.4%) had at least improvement of one point of the Cleveland Clinic Incontinence score (CCIS); 13/57 (22.8%) reported a significant improvement of continence (delta score >50%). Five of the twelve patients (41.6%) with CCIS < 5 at baseline became incontinent over time. The neurological level was not associated with a worse continence outcome. Work on stool consistency and transanal irrigation were the most useful strategies in those with significant improvement of continence. CONCLUSIONS Using conventional strategies, a benefit on fecal continence occurs in only one out of five patients suffering from Spina Bifida and continent patients at baseline can develop fecal incontinence over time. A strategy targeting improved control of defecation (transanal irrigation) and a standardization of follow-up protocol might be beneficial.
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Affiliation(s)
- Charlène Brochard
- CHU Rennes, Service d'Explorations Fonctionnelles Digestives, Université Rennes, Rennes, France
| | - Benoît Peyronnet
- CHU Rennes, Service d'Urologie, Université Rennes, Rennes, France
| | - Juliette Hascoet
- CHU Rennes, Service d'Urologie, Université Rennes, Rennes, France
| | | | - Andréa Manunta
- CHU Rennes, Service d'Urologie, Centre Référence National Maladies Rares Spina Bifida-dysraphismes, Rennes, France
| | - Magali Jezequel
- CHU Rennes, Centre Référence National Maladies Rares Spina Bifida-dysraphismes, Rennes, France
| | - Quentin Alimi
- CHU Rennes, Service d'Urologie, Centre Référence National Maladies Rares Spina Bifida-dysraphismes, Rennes, France
| | - Alain Ropert
- CHU Rennes, Service d'Explorations Fonctionnelles Digestives, Université Rennes, Rennes, France
| | | | - Guillaume Bouguen
- CHU Rennes, Service des Maladies de l'Appareil Digestif, Université Rennes, INSERM, Institut NUMECAN (Nutrition Metabolisms and Cancer), Rennes, France
| | - Laurent Siproudhis
- CHU Rennes, Service des Maladies de l'Appareil Digestif, Université Rennes, INSERM, Institut NUMECAN (Nutrition Metabolisms and Cancer), Rennes, France
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