Anal incontinence in women presenting for gynecologic care: prevalence, risk factors, and impact upon quality of life

Accuracy of patient-reported bowel symptoms for fecal incontinence: Historical recall versus prospective evaluation

INTRODUCTION

Fecal incontinence (FI) is characterized by both irregular and unpredictable bowel symptoms. An accurate history of symptoms is important for diagnosis and guiding management. Whether a patient's history of bowel symptoms is reliable or if there is recall bias is unknown.

AIM

To evaluate the accuracy of FI symptoms based on patient's recall compared with a prospective stool diary.

METHODS

FI (Rome IV) patients completed a bowel questionnaire that included leakage episodes and stool consistency. Subsequently they completed a one-week FI stool diary. Agreement and correlation between historical recall and stool diary were compared.

RESULTS

One hundred patients participated. On average they reported 12 bowel movements (BMs) and five FI episodes per week. Fifty-two percent had completed under-graduation, 33% high school and 15% postgraduation. Using recall, 23% of patients accurately reported the number of FI episodes, whereas 41% underestimated and 36% overestimated its prevalence compared to the FI diary. Similarly, the concordance for the number of BMs was 30%, urgency was 54%, amount of stool leakage was 16%, and stool consistency was 12.5%. The concordance for nocturnal FI events, use of pads and lack of stool awareness were 63%, 75%, and 66.6% respectively.

CONCLUSION

There is poor concordance for key bowel symptoms including the number of FI episodes as reported by FI patients, suggesting significant recall bias. Thus, historical recall of chronic FI symptoms may be less accurate. A prospective stool diary could provide more accurate information for the evaluation of FI patients.

Pelvic floor muscle training with biofeedback or feedback from a physiotherapist for urinary and anal incontinence after childbirth - a systematic review

BACKGROUND

Childbirth is one of the biggest risk factors for incontinence. Urinary and anal incontinence can cause pain and social limitations that affect social life, cohabitation, and work. There is currently no up-to-date literature study on the effect of pelvic floor muscle training with feedback from a physiotherapist, which involves verbal instructions based on vaginal and anal digital palpation, compared to treatment without feedback (e.g., recommendations for pelvic floor muscle training).

AIM

The objective of this systematic review was to examine the scientific evidence regarding the impact of pelvic floor muscle training (PFMT) with feedback from a physiotherapist and/or biofeedback on urinary and anal incontinence in women during the first six months following vaginal delivery, compared to treatment without feedback.

METHODS

The literature search was conducted in the databases PubMed, Cochrane, and CINAHL. In addition, a manual search was conducted. The search terms consisted of MeSH terms and synonyms in the respective search block including population, intervention, and study design, as well as the terms pelvic floor and postpartum. An evaluation of each included study was conducted for methodological quality, evidence value, and clinical relevance.

RESULTS

Eight studies were included, three of which showed a significant difference between groups, in favor of the intervention group that received pelvic floor muscle training with feedback from a physiotherapist and/or biofeedback. Due to the varying results and insufficient quality for the majority of the studies, the scientific basis was considered insufficient.

CONCLUSION

The scientific evidence for pelvic floor muscle training with feedback from a physiotherapist or biofeedback on postpartum urinary and anal incontinence compared to treatment without feedback is considered insufficient. Further research on the subject is needed. The study is registered in PROSPERO CRD42022361296.

Flatus Incontinence and Fecal Incontinence: A Case-Control Study

BACKGROUND

Incontinence to gas can be a troublesome symptom impacting quality of life for patients even in the absence of fecal incontinence. Whether isolated flatus incontinence represents part of the spectrum of true fecal incontinence or a separate condition with a different pathophysiology remains unclear.

OBJECTIVE

This study aimed to evaluate the clinical features and anorectal physiology in women presenting with severe isolated flatus incontinence compared to women with fecal incontinence and healthy asymptomatic women.

DESIGN

This was a retrospective case-control study of prospectively collected data.

SETTINGS

Data from participants were obtained from a single tertiary Neurogastroenterology Unit in Sydney, Australia.

PATIENTS

Data from 34 patients with severe isolated flatus incontinence, 127 women with fecal incontinence' and 44 healthy women were analyzed.

MAIN OUTCOME MEASURES

The primary outcomes were clinical (including demographic, obstetric, and symptom variables) and physiological differences across the 3 groups.

RESULTS

Patients with flatus incontinence were significantly younger (mean 39 versus 63 years; p = 0.0001), had a shorter history of experiencing their symptoms ( p = 0.0001), and had harder stool form than patients with fecal incontinence ( p = 0.02). Those with flatus incontinence had an adverse obstetric history and impaired anorectal physiology (motor and sensory, specifically rectal hypersensitivity) but to a lesser extent than patients with fecal incontinence.

LIMITATIONS

This study was limited by its retrospective design and modest sample size.

CONCLUSIONS

Anorectal physiology was impaired in patients with flatus incontinence compared to healthy controls, but to a lesser extent than in those with fecal incontinence, raising the possibility that flatus incontinence could be a precursor to fecal incontinence. As clinical and physiological findings are different from healthy controls (including the presence of visceral hypersensitivity), isolated flatus incontinence should be considered a distinct clinical entity (like other functional GI disorders), or possibly part of an incontinence spectrum rather than purely a normal phenomenon. See Video Abstract at http://links.lww.com/DCR/B946 .

INCONTINENCIA DE FLATOS E INCONTINENCIA FECAL UN ESTUDIO DE CASOS Y CONTROLES

ANTECEDENTES:La incontinencia de gases puede ser un síntoma molesto que afecta la calidad de vida de los pacientes incluso en ausencia de incontinencia fecal. Aún no está claro si la incontinencia de flatos aislada representa parte del espectro de la incontinencia fecal verdadera o una condición separada con una fisiopatología poco clara.OBJETIVO:Evaluar las características clínicas y la fisiología anorrectal en mujeres que presentan incontinencia grave aislada de flatos, en comparación con la incontinencia fecal y mujeres sanas asintomáticas.DISEÑO:Este fue un estudio retrospectivo de casos y controles de datos recolectados prospectivamente.AJUSTE:Los datos de los participantes se obtuvieron de una sola Unidad de Neurogastroenterología terciaria en Sydney, Australia.PACIENTES:Se analizaron los datos de 34 pacientes con incontinencia grave aislada de flatos, junto con 127 mujeres con incontinencia fecal y 44 mujeres sanas.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados primarios fueron clínicos (incluidas las variables demográficas, obstétricas y de síntomas), así como las diferencias fisiológicas entre los tres grupos.RESULTADOS:Los pacientes con incontinencia de flatos eran significativamente más jóvenes (media de 39 años frente a 63 años, p = 0,0001), tenían un historial más corto de experimentar sus síntomas (p = 0,0001) y tenían heces más duras que los pacientes con incontinencia fecal (p = 0,02). Aquellos con incontinencia de flatos tenían antecedentes obstétricos adversos y fisiología anorrectal alterada (motora y sensorial, específicamente hipersensibilidad rectal); aunque en menor medida que las pacientes con incontinencia fecal.LIMITACIONES:Este estudio estuvo limitado por su diseño retrospectivo y tamaño de muestra modesto.CONCLUSIONES:La fisiología anorrectal se vio afectada en las pacientes con incontinencia de flatos en comparación con las controles sanos, pero en menor medida que en aquellas con incontinencia fecal, lo que plantea la posibilidad de que la incontinencia de flatos pueda ser un precursor de la incontinencia fecal. Dado que los hallazgos clínicos y fisiológicos son diferentes a los de los controles sanos (incluida la presencia de hipersensibilidad visceral), la incontinencia de flatos aislada debe considerarse como una entidad clínica distinta (al igual que otros trastornos gastrointestinales funcionales), o posiblemente como parte de un espectro de incontinencia en lugar de un trastorno puramente a un fenómeno normal. Consulte Video Resumen en http://links.lww.com/DCR/B946 . (Traducción-Dr Yolanda Colorado ).

Randomized controlled trial of home biofeedback therapy versus office biofeedback therapy for fecal incontinence

BACKGROUND

Biofeedback therapy is useful for treatment of fecal incontinence (FI), but is not widely available and labor intensive. We investigated if home biofeedback therapy (HBT) is non-inferior to office biofeedback therapy (OBT).

METHODS

Patients with FI (≥1 episode/week) were randomized to HBT or OBT for 6 weeks. HBT was performed daily using novel device that provided resistance training and electrical stimulation with voice-guided instructions. OBT consisted of six weekly sessions. Both methods involved anal strength, endurance, and coordination training. Primary outcome was change in weekly FI episodes. FI improvement was assessed with stool diaries, validated instruments (FISI, FISS, and ICIQ-B), and anorectal manometry using intention-to-treat analysis.

KEY RESULTS

Thirty (F/M = 26/4) FI patients (20 in HBT, 10 in OBT) participated. Weekly FI episodes decreased significantly after HBT (Δ ± 95% confidence interval: 4.7 ± 1.8, compared with baseline, p = 0.003) and OBT (3.7 ± 1.6, p = 0.0003) and HBT was non-inferior to OBT (p = 0.2). The FISI and FISS scores improved significantly in HBT group (p < 0.02). Bowel pattern, bowel control, and quality of life (QOL) domains (ICIQ-B) improved significantly in HBT arm (p < 0.023). Resting and maximum squeeze sphincter pressures significantly improved in both HBT and OBT groups and sustained squeeze pressure in HBT, without group differences.

CONCLUSIONS & INFERENCES

Home biofeedback therapy is non-inferior to OBT for FI treatment. Home biofeedback is safe, effective, improves QOL, and through increased access could facilitate improved management of FI.

Representation of Minority Groups in Key Pelvic Floor Disorder Trials

BACKGROUND

Multicenter randomized clinical trials on pelvic floor disorders (PFDs) support evidence-based care. However, many of these studies include homogenous study populations lacking diversity. Heterogeneous sampling allows for greater generalizability while increasing knowledge regarding specific subgroups. The racial/ethnic makeup of key pelvic floor disorder (PFD) trials has not been examined.

OBJECTIVE

This study aimed to investigate racial/ethnic representation in major PFD clinical trials in comparison to racial/ethnic distribution of PFD in the National Health and Nutritional Examination Survey (NHANES).

METHODS

Demographic data were extracted from completed PFD Network (PFDN) and Urinary Incontinence Treatment Network studies, which have resulted in nearly 200 publications. Prevalence of PFD by race/ethnicity was obtained from the NHANES. A representative index (Observed "n" by PFD study/Expected "n" based on the NHANES-reported prevalence) was calculated as a measure of representation. Meta-analyses were performed for each outcome and overall with respect to race/ethnicity.

RESULTS

Eighteen PFDN/Urinary Incontinence Treatment Network studies were analyzed. White women comprised 70%-89% of PFD literature; Black women, 6%-16%; Hispanic women, 9%-15%; Asians, 0.5%-6%; and American Indians, 0%-2%. Representation of White women was higher in 13 of 18 PFDN studies compared with the NHANES prevalence data. Representation of Black women was either decreased or not reported in 10 of 18 index studies compared with the NHANES prevalence data. Hispanic women were absent or underrepresented in 7 of 18 PFDN studies compared with the prevalence data.

CONCLUSIONS

Our examination of PFDN and other landmark trials demonstrates inconsistent reporting of minority subgroups, limiting applicability with respect to minority populations. Our study suggests that PFD research would benefit from targeted sampling of minority groups.

Which factors are associated with anal incontinence after obstetric anal sphincter injury?

OBJECTIVES

Obstetric anal sphincter injury (OASI) is an important factor in the etiology of anal incontinence. This study aimed to evaluate whether anal sphincter defects, levator avulsion or levator ballooning after OASI are associated with severity of anal incontinence. Furthermore, we evaluated whether factors such as constipation and altered stool consistency are associated with symptoms of incontinence after OASI.

METHODS

In this multicenter prospective observational cohort study, women with OASI were invited to participate at least 3 months after primary repair. All women completed validated questionnaires, including St Mark's incontinence score, Bristol stool scale (BSS) and Cleveland clinic constipation score (CCCS), and underwent four-dimensional (4D) transperineal ultrasound for assessment of the levator ani muscle and anal sphincter.

RESULTS

In total, 220 women were included. Median follow-up was 4 months (range, 3-98 months). Univariate linear regression analysis showed an association of St Mark's incontinence score with a residual defect of the external anal sphincter (EAS) (β, 1.55 (95% CI, 0.04-3.07); P = 0.045), higher parity (β, 0.85 (95% CI, 0.02-1.67); P = 0.046), BSS (β, 1.28 (95% CI, 0.67-1.89); P < 0.001) and CCCS (β, 0.36 (95% CI, 0.18-0.54); P < 0.001). However, multivariate linear regression found an association of St Mark's incontinence score only with BSS (β, 1.50 (95% CI, 0.90-2.11); P < 0.001) and CCCS (β, 0.46 (95% CI, 0.29-0.63); P < 0.001).

CONCLUSIONS

Residual defects of the EAS, detected on 4D transperineal ultrasound, are associated with severity of anal incontinence symptoms measured using St Mark's incontinence score 4 months after OASI repair. Furthermore, clinical factors such as constipation and altered stool consistency appear to influence this association and may therefore play a more important role in clinical management. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

The Role of Obesity on Urinary and Anal Incontinence in women: a review

Obesity is increasing worldwide with significant healthcare implications. We searched PubMed/MEDLINE, Embase and Cochrane Library for articles registered until June 2020 to explore the relationship between obesity, urinary (UI) and anal incontinence (AI). Obesity is associated with low-grade, systemic inflammation and pro-inflammatory cytokine release, producing reactive oxygen species and oxidative stress (1). This alters collagen metabolism and, in combination with increased intraabdominal pressure, contributes to UI development. Whereas in AI, stool consistency may be a factor. Weight loss can reduce UI and should be a management focus, however effect on AI is less clear. Keywords: Obesity, Urinary incontinence, Anal incontinence.

Is pelvic floor muscle contractility an important factor in anal incontinence?

OBJECTIVE

Pelvic floor muscle contractility (PFMC) may contribute to anal continence. The aim of this study was to assess the association between clinical and sonographic measures of PFMC and anal incontinence (AI) symptoms, after controlling for anal sphincter and levator ani muscle (LAM) trauma.

METHODS

This was a retrospective study of 1383 women assessed at a tertiary center between 2013 and 2016. All patients underwent an interview, including the St Mark's incontinence score (SMIS) in those who reported AI symptoms, a clinical examination, including assessment of PFMC using the modified Oxford scale (MOS), and four-dimensional translabial ultrasound (TLUS). Sonographic measures of PFMC, i.e. cranioventral shift of the bladder neck (BN) and reduction of anteroposterior (AP) diameter of the levator hiatus, were measured offline using ultrasound volumes obtained at rest and on maximum pelvic floor contraction. The reviewer was blinded to all clinical data.

RESULTS

Of the 1383 patients assessed during the study period, seven were excluded due to missing imaging data, leaving 1376 for analysis. Mean age of the participating women was 55 years and mean body mass index was 29 kg/m² . AI was reported by 221 (16.1%) women, with a mean SMIS of 11.8. Mean MOS grade was 2.3. On TLUS, mean BN cranioventral shift was 5.9 mm and mean AP diameter reduction was 8.1 mm. LAM avulsion and significant external anal sphincter (EAS) defect were diagnosed in 24.8% and 8.7% patients, respectively. On univariate analysis, sonographic measures of PFMC were not associated with AI. Lower MOS grade was associated with symptoms of AI; however, statistical significance was lost on multivariate analysis.

CONCLUSION

Clinical and sonographic measures of PFMC were not significantly associated with AI symptoms after controlling for EAS and LAM trauma. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Enhancing the identification of anal incontinence in women of reproductive age

Anal incontinence is an unpredictable and debilitating condition that can significantly reduce quality of life. Symptoms include the involuntary loss of solid and/or liquid stool, flatus incontinence and rectal urgency. Pregnancy and childbirth are two major factors that increase the risk of anal incontinence in women of reproductive age. Women at high risk of anal incontinence include those with a known history of the condition and those who have experienced severe perineal trauma, particularly after injury to the anal sphincters (third-degree and fourth-degree tears). Routine screening for anal incontinence of women in high-risk groups during pregnancy and after childbirth appears to be limited in clinical practice. This article discusses the potential benefits of screening for anal incontinence, outlines the factors that inhibit and enable screening, describes current bowel screening tools and their limitations, and explores how the identification of anal incontinence in women of reproductive age could be improved.

The effect of preoperative pelvic floor muscle training on urinary and colorectal-anal distress in women undergoing pelvic organ prolapse surgery-a randomized controlled trial

Introduction and hypothesis

Pelvic floor muscle training (PFMT) improves urinary incontinence and mild pelvic organ prolapse (POP). We aimed to investigate the effect of preoperative PFMT on urinary and colorectal-anal distress and related quality of life (QoL) in women with severe POP scheduled for surgery.

Methods

Randomized controlled trial of 159 women scheduled for POP surgery (intervention = 81, controls = 78). Intervention consisted of daily PFMT from inclusion to the day of surgery. Symptoms and QoL were assessed at inclusion, day of surgery and 6 months postoperatively using the Urinary Distress Inventory (UDI-6), Colorectal-Anal Distress Inventory (CRADI-8), Urinary Impact Questionnaire (UIQ) and Colorectal-Anal Impact Questionnaire (CRAIQ) (range 0–100). Mixed model statistical analyses were used.

Results

One hundred fifty-one (95%) women completed the study (intervention = 75, controls = 76). Mean waiting times until surgery and follow-up were 22 and 28 weeks. There was no difference in mean postoperative symptom and QoL scores (95% CI) between the intervention and control group: UDI-6 16 (12–21) vs. 17 (13–22), CRADI-8 15 (11–18) vs. 13 (10–16), UIQ 11 (7–15) vs. 10 (6–13) and CRAIQ 5 (2–7) vs. 6 (4–9), all p > 0.05. Overall mean scores were reduced from baseline to postoperative follow-up: UDI-6 37 (33–41) vs. 17 (14–20), CRADI-8 22 (19–25) vs. 14 (11–16); UIQ 28 (24–32) vs. 10 (7–13) and CRAIQ 16 (12–19) vs. 5 (3–7), all p < 0.01.

Conclusions

We found no added effect of preoperative PFMT on symptoms or QoL related to urinary and colorectal-anal distress in women scheduled for POP surgery. They achieved symptomatic improvement postoperatively regardless of PFMT.

Clinical trial registration

The study was registered in clinicaltrials.gov: NCT 03,064,750.

Patient-defined goals for the treatment of fecal incontinence: a qualitative analysis among women attending a urogynecology clinic

INTRODUCTION AND HYPOTHESIS

Fecal incontinence treatment goals are understudied and are not described for women presenting to care. Our objective was to explore patient-reported goals for fecal incontinence management among women presenting for care at a pelvic floor disorders clinic and develop a conceptual framework that captures the range of desired treatment outcomes.

METHODS

A qualitative analysis of patient-reported goals for women with fecal incontinence attending a pelvic floor disorders clinic from October 2017-November 2019 was conducted. A team-based approach was used to identify themes and emerging concepts and develop a conceptual framework.

RESULTS

One hundred patients met the inclusion criteria. Mean age was 58 ± 14 years; 67% were White and 46% non-Hispanic. Seventy-nine percent of women had diagnosis(es) of prolapse, urinary complaints, or another pelvic floor disorder. From 230 unique goals identified, five thematic categories emerged: Emotional Status, Functional Status, Concurrent Pelvic Floor Disorders, Care Seeking, and Treatment Aspirations. Thematic domains not previously represented in other qualitative work include patients' focus on treatment for global pelvic health rather than solely on fecal incontinence and treatment aspirations ranging from improvement to cure. Our model captures the close relationship between all pelvic floor disorders and emotion, which in return affects all facets of care.

CONCLUSIONS

Women with fecal incontinence report a range of treatment goals from improvement to complete resolution of symptoms. Focusing treatment on patient goals by addressing global pelvic health and negotiating realistic treatment outcomes may improve care in this population.

Pelvic floor dysfunction distress is correlated with quality of life, but not with muscle function

OBJECTIVE

To analyze the relationship between the symptoms of pelvic floor dysfunction (PFD) and quality of life (QoL), as well as the function of the pelvic floor muscle (PFM) in women with urinary incontinence (UI).

METHODS

A cross-sectional study conducted in two centers in Brazil (Northeast and Southeast regions) with women with stress urinary incontinence (SUI) and mixed urinary incontinence (MUI). Data on pelvic floor symptoms, discomfort and impact on QoL were collected using the Pelvic Floor Distress Inventory-short form (PFDI-SF-20) and the Pelvic Floor Impact Questionnaire (PFIQ-7) instruments. PFM function was assessed by palpation (PERFECT scale) and manometry. Pearson's correlation test, analysis of variance (ANOVA) and the Student's t test were used to discriminate the differences, adopting a significance level of 5%.

RESULTS

A total of 72 women participated in the study (mean age 51.7 ± 11.9 years). The presence and discomfort of pelvic floor symptoms (PFDI-SF-20) were correlated with QoL (PFIQ-7) (r = 0.52, p < 0.001). Deficits in PFM function (power and pressure) were observed, however, there was no correlation between these with the presence and discomfort of the pelvic floor symptoms (PFDI-SF-20).

CONCLUSION

Greater discomfort due to PFD symptoms were correlated with a worse QoL. However, the relationship between symptoms and PFM function was not significant. These results reinforce the need to assess the aspects of activity and participation which compose functionality and QoL, and not only the PFM functions in women with UI.

Prevalence of anal sphincter defects and association with anal incontinence in women scheduled for pelvic organ prolapse surgery

AIMS

Some women with pelvic organ prolapse (POP) have concomitant symptoms of anal incontinence. Our aim was to assess the prevalence of anal sphincter defects and the association with incontinence in women undergoing POP surgery.

METHODS

Cross-sectional study of 200 women scheduled for POP surgery. They answered yes/no and graded any symptoms of fecal and flatal incontinence on a visual analog scale (0-100). 3D/4D transperineal ultrasound was used to assess internal (IAS) and external anal sphincter (EAS) defects. A defect of ≥30° in ≥4 of 6 slices on tomographic imaging was regarded significant. The association between incontinence and sphincter defects was tested with multivariable logistic regression analysis.

RESULTS

The prevalence of any sphincter defect was 50/200 (25%). Combined IAS/EAS defect was found in 19/200 (9.5%) women, 8/200 (4.0%) had isolated IAS, and 23/200 (11.5%) had isolated EAS defects. In women with defect and intact IAS, 37% and 11% reported fecal incontinence, respectively, adjusted odds ratio (aOR) 2.3 (95% confidence interval [CI], 0.7-7.0), p = .147 and in women with defect versus intact EAS, 36% and 9% had fecal incontinence, aOR 4.0 (95% CI, 1.5-10.8), p = .005. In women with defect and intact IAS, 85% versus 43% reported flatal incontinence, aOR 5.2 (95% CI, 1.6-17.2), p = .007 and in women with defect versus intact EAS, 71% versus 43% had flatal incontinence, aOR 1.9 (95% CI, 0.8-4.5), p = .131.

CONCLUSIONS

One of four women scheduled for POP surgery had an anal sphincter defect. EAS defects were associated with fecal incontinence and IAS defects were strongly associated with flatal incontinence.

Quality of life and 3D-EUS assessment for anal incontinence after childbirth

BACKGROUND

the incidence of obstetric sphincter tears has risen to 15-30% and the prevalence of anal incontinence (AI) symptoms after childbirth may be as high as 40%. The present study evaluates the correlation between obstetric injuries detected by endoanal ultrasound (3D-EUS) and AI symptoms, as well as their impact on the quality of life (QOL) of women after childbirth.

METHODS

a prospective observational study was performed of pregnant women evaluated before (baseline) and three months after childbirth to ensure the integrity of the anal sphincters and to evaluate possible injuries. The Fecal Incontinence Quality of Life (FIQL) questionnaire and the Cleveland Clinic Score of Incontinence (Wexner) were completed before and after childbirth. The questionnaire results were correlated with an assessment of sphincter defects performed by 3D-EUS.

RESULTS

a total of 56 females were included in the study. Overall, 48% developed symptoms of AI after childbirth, with a significant decrease in their FIQL compared to the initial evaluation, 3.9 (0.05) vs 3.4 (0.8), respectively (p = 0.000). In addition, 42% of the cohort presented with some kind of obstetric sphincter defect on the 3D-EUS. Instrumental assisted delivery and the sphincter defects were the only two significant factors identified via multivariate analysis that were associated with a decrease in QOL (0.4, 95% CI, 0.07-0.8).

CONCLUSIONS

AI after childbirth was associated with a huge impact on QOL, especially in patients with sphincter injuries. A complete clinical evaluation, including 3D-EUS, is recommended to prevent, manage or treat AI in primiparous females.

Impact of treatment for fecal incontinence on constipation symptoms

OBJECTIVE

Defecatory symptoms, such as a sense of incomplete emptying and straining with bowel movements, are paradoxically present in women with fecal incontinence. Treatments for fecal incontinence, such as loperamide and biofeedback, can worsen or improve defecatory symptoms, respectively. The primary aim of this study was to compare changes in constipation symptoms in women undergoing treatment for fecal incontinence with education only, loperamide, anal muscle exercises with biofeedback or both loperamide and biofeedback. Our secondary aim was to compare changes in constipation symptoms among responders and nonresponders to fecal incontinence treatment.

STUDY DESIGN

This was a planned secondary analysis of a randomized controlled trial comparing 2 first-line therapies for fecal incontinence in a 2 × 2 factorial design. Women with at least monthly fecal incontinence and normal stool consistency were randomized to 4 groups: (1) oral placebo plus education only, (2) oral loperamide plus education only, (3) placebo plus anorectal manometry-assisted biofeedback, and (4) loperamide plus biofeedback. Defecatory symptoms were measured using the Patient Assessment of Constipation Symptoms questionnaire at baseline, 12 weeks, and 24 weeks. The Patient Assessment of Constipation Symptoms consists of 12 items that contribute to a global score and 3 subscales: stool characteristics/symptoms (hardness of stool, size of stool, straining, inability to pass stool), rectal symptoms (burning, pain, bleeding, incomplete bowel movement), and abdominal symptoms (discomfort, pain, bloating, cramps). Scores for each subscale as well as the global score range from 0 (no symptoms) to 4 (maximum score), with negative change scores representing improvement in defecatory symptoms. Responders to fecal incontinence treatment were defined as women with a minimally important clinical improvement of ≥5 points on the St Mark's (Vaizey) scale between baseline and 24 weeks. Intent-to-treat analysis was performed using a longitudinal mixed model, controlling for baseline scores, to estimate changes in Patient Assessment of Constipation Symptoms scores from baseline through 24 weeks.

RESULTS

At 24 weeks, there were small changes in Patient Assessment of Constipation Symptoms global scores in all 4 groups: oral placebo plus education (-0.3; 95% confidence interval, -0.5 to -0.1), loperamide plus education (-0.1, 95% confidence interval, -0.3 to0.0), oral placebo plus biofeedback (-0.3, 95% confidence interval, -0.4 to -0.2), and loperamide plus biofeedback (-0.3, 95% confidence interval, -0.4 to -0.2). No differences were observed in change in Patient Assessment of Constipation Symptoms scores between women randomized to placebo plus education and those randomized to loperamide plus education (P = .17) or placebo plus biofeedback (P = .82). Change in Patient Assessment of Constipation Symptoms scores in women randomized to combination loperamide plus biofeedback therapy was not different from that of women randomized to treatment with loperamide or biofeedback alone. Responders had greater improvement in Patient Assessment of Constipation Symptoms scores than nonresponders (-0.4; 95% confidence interval, -0.5 to -0.3 vs -0.2; 95% confidence interval, -0.3 to -0.0, P < .01, mean difference, 0.2, 95% confidence interval, 0.1-0.4).

CONCLUSION

Change in constipation symptoms following treatment of fecal incontinence in women are small and are not significantly different between groups. Loperamide treatment for fecal incontinence does not worsen constipation symptoms among women with normal consistency stool. Women with clinically significant improvement in fecal incontinence symptoms report greater improvement in constipation symptoms.

ACOG Practice Bulletin No. 210: Fecal Incontinence

Fecal incontinence, or the involuntary leakage of solid or loose stool, is estimated to affect 7-15% of community-dwelling women (1). It is associated with reduced quality of life, negative psychologic effects, and social stigma (2), yet many women do not report their symptoms or seek treatment. Less than 3% of women who do self-report fecal incontinence will have this diagnosis recorded in their medical record (3). Obstetrician-gynecologists are in a unique position to identify women with fecal incontinence because pregnancy, childbirth, obstetric anal sphincter injuries (OASIS), and pelvic floor dysfunction are important risk factors that contribute to fecal incontinence in women. The purpose of this Practice Bulletin is to provide evidence-based guidelines on the screening, evaluation, and management of fecal incontinence to help obstetrician-gynecologists diagnose the condition and provide conservative treatment or referral for further work up and surgical management when appropriate. For discussion on fecal incontinence associated with OASIS, see Practice Bulletin No. 198, Prevention and Management of Obstetric Lacerations at Vaginal Delivery (4).

Quality of life in 1870 patients with constipation and/or fecal incontinence: Constipation should not be underestimated

BACKGROUND

Quality of life is increasingly seen as important, but remains difficult to assess in patients with functional anorectal complaints.

OBJECTIVE

We aimed to quantify quality of life and to analyse the symptomatic descriptors associated with a poor outcome in patients with faecal incontinence (FI) and/or constipation.

METHODS

The characteristics of the patients, data from self-administered questionnaires and from physical examinations were evaluated prospectively for all cases of functional anorectal disease over a period of thirteen years. Functional anorectal disease included faecal incontinence (FI) and/or constipation. Patients with scores in the lowest quartile of the Gastrointestinal Quality of Life Index (GIQLI) were considered to have suffered severe alterations to their quality of life, and were compared with the other patients.

RESULTS

In total, 1870 patients with functional anorectal disease were included (470 with a severely altered quality of life (GIQLI < 70)). Constipation predominated (1212/1870; 65.1%) and severe FI was frequent (761/1870; 40.9%). Severely altered quality of life was significantly associated with constipation (P = 0.0001), urinary urgency and incontinence (P = 0.0001), depression (P = 0.001), diabetes (P = 0.0224), severe FI (P = 0.0001), neurological disease (P = 0.0138) and liquid stools (P = 0.0002) in multivariate analysis.

CONCLUSION

Several treatable factors are associated to an impaired quality of life in patients with functional anorectal disorders. Intervention studies are mandatory (stool consistency and frequency).

Resting vector volume measured before ileostomy reversal may be a predictor of major fecal incontinence in patients with mid or low rectal cancer: a longitudinal cohort study using a prospective clinical database

PURPOSE

Despite a high incidence of fecal incontinence following sphincter-preservation surgery (SPS), there are no definitive factors measured before ileostomy reversal that predict fecal incontinence. We investigated whether vector volume anorectal manometry before ileostomy reversal predicts major fecal incontinence following SPS in patients with mid or low rectal cancer.

METHODS

This longitudinal prospective cohort study comprised 173 patients who underwent vector volume anorectal manometry before ileostomy reversal. The Fecal Incontinence Severity Index was measured 1 year after the primary SPS and classified as major incontinence (FISI score ≥ 25) or continent/minor incontinence (FISI score < 25). Multivariable logistic regression analysis was used to identify predictors of major incontinence.

RESULTS

Ninety-two patients (53.1%) had major incontinence. Although tumor stage, location, and neoadjuvant chemoradiotherapy were comparable, the major incontinence group had lower resting pressure (28.4 vs. 34.3 mmHg, P = 0.027), greater asymmetry at rest (39.1% vs. 34.1%, P = 0.002) and squeezing (34.2% vs. 31.4%, P = 0.046), shorter sphincter length (3.3 vs. 3.7 cm, P = 0.034), and lower resting vector volume (143,601 vs. 278,922 mmHg² mm, P < 0.001) compared with the continent/minor incontinence group. Resting vector volume was the only independent predictor of major incontinence (odds ratio = 0.675 per 100,000 mmHg² mm, 95% confidence interval, 0.532-0.823; P = 0.006).

CONCLUSIONS

This study revealed that resting vector volume before ileostomy reversal may predict major fecal incontinence. We suggest that the physiology of the anorectum should be discussed with patients before ileostomy reversal in patients at high risk of fecal incontinence.

A systematic review of the literature reporting on randomised controlled trials comparing treatments for faecal incontinence in adults

AIM

To perform a review of the literature reporting on randomised controlled trials (RCTs) comparing treatments for faecal incontinence (FI) in adults.

METHODS

A literature search of MEDLINE, Embase, Science Citation Index Expanded and Cochrane was performed in order to identify RCTs reporting on treatments for FI.

RESULTS

The review included 60 RCTs reporting on 4838 patients with a mean age ranging from 36.8 to 88 years. From the included RCTs, 32 did not identify a significant difference between the treatments compared. Contradictory results were identified in RCTs comparing percutaneous posterior tibial nerve stimulation and transcutaneous tibial nerve stimulation versus sham stimulation, biofeedback-pelvic floor muscle training (BF-PFMT) versus PFMT, and between bulking agents such as PTQ^TM versus Durasphere^®. In two separate RCTs, combination treatment of amplitude-modulated medium frequency stimulation and electromyography-biofeedback (EMG-BF), was noted to be superior to EMG-BF and low-frequency electrical stimulation alone. Combination of non-surgical treatments such as BF with sphincteroplasty significantly improved continence scores compared to sphincteroplasty alone. Surgical treatments were associated with higher rates of serious adverse events compared to non-surgical interventions.

CONCLUSIONS

The current evidence has not identified significant differences between treatments for FI, and where differences were identified, the results were contradictory between RCTs.

Does flatus incontinence matter?

INTRODUCTION AND HYPOTHESIS

This study aimed to determine whether incontinence to flatus is associated with women's bother in a symptomatic population and with sonographically diagnosed external anal sphincter (EAS) trauma.

METHODS

This is a retrospective study of women attending a tertiary urogynecological unit between May 2013 and November 2015. Baseline evaluation included a standardized interview with St. Mark's Incontinence Score (SMIS) and visual analog scale (VAS) assessment for bother, as well as a physical examination and translabial pelvic floor ultrasound. At least one volume obtained covered the entire length of the EAS. These volumes were analyzed with the reviewer blinded to all clinical data.

RESULTS

During the inclusion period, 1104 patients visited the unit. Fifty-three patients were excluded from the study for missing data, leaving 1051 for final analysis. Mean age was 57 years (56-58) and mean body mass index (BMI) 29.1 kg/m² (28.8-29.6). The prevalence of any anal incontinence (AI) and flatus incontinence were 16.4% (172/1051) and 13.9% (146/1051), respectively. In the group of patients with AI, mean SMIS was 11.8 (11.0-12.6), and mean VAS for AI bother was 5.4 (5.0-5.9). Significant EAS trauma was detected in 9.8% (103/1051) of patients and was associated with flatus incontinence (p = 0.002). Including a flatus incontinence question in the SMIS questionnaire improved the prediction of patient bother from AI (R² 87.8% versus R² 86.3%, p = 0.04).

CONCLUSIONS

Flatus incontinence is associated with ultrasound findings of EAS trauma and with higher patient bother from AI.

High-Resolution Anorectal Manometry - New Insights in the Diagnostic Assessment of Functional Anorectal Disorders

Functional anorectal disorders such as faecal incontinence (FI), functional anorectal pain, and functional defecation disorders (FDD) are highly prevalent and represent a high socioeconomic burden. Several tests of anorectal function exist in this setting; however, high-resolution anorectal manometry (HR-ARM) is a new tool that depicts pressure all along the anal canal and can assess rectoanal coordination. HR-ARM is used in the diagnosis of FI and especially FDD although data in health is still sparse, and pressure phenomena seen during simulated defecation, such as dyssynergia, are highly prevalent in health.

Prevalence and predictors of double incontinence 1 year after first delivery

INTRODUCTION AND HYPOTHESIS

Urinary (UI) and anal incontinence (AI) are common pelvic floor disorders (PFD), and postpartum women experiencing double incontinence (DI), the combination of UI and AI, tend to have more severe symptoms and a greater impact on quality of life. Our objective was to investigate the prevalence and predictors of postpartum DI and UI alone 1 year after first delivery.

METHODS

In this prospective cohort study, 976 women reported the prevalence of DI and UI alone 1 year after their first delivery in one of two hospitals in Norway using the St Marks score and the ICI-Q UI SF.

RESULTS

DI was significantly reduced from 13% in late pregnancy to 8% 1 year later, whereas 30% reported UI at both time points. Incontinence in late pregnancy predicted incontinence 1 year after delivery. Higher age was associated with UI alone. Compared with caesarean delivery, normal vaginal or instrumental delivery increased the risk of UI alone more than three and four times respectively. Obstetric anal sphincter injuries showed a four-fold increase in the risk of DI.

CONCLUSIONS

Nearly 50% reported incontinence symptoms 1 year after first delivery. Continence status during pregnancy was one of the main predictors of postpartum continence status. Mode of delivery increased the risk of postpartum UI, whereas obstetric anal sphincter injuries increased the risk of postpartum DI.

Irritable Bowel Syndrome and Quality of Life in Women With Fecal Incontinence

OBJECTIVES

The objectives of this work were to determine the prevalence of irritable bowel syndrome (IBS) and IBS subtypes in women presenting for fecal incontinence (FI) treatment and to assess the impact of IBS on FI symptoms and quality of life (QOL).

METHODS

In this multicenter prospective cohort study, women reported at least monthly solid, liquid, or mucus FI. Rome III clinical criteria defined IBS. Women also self-reported having an IBS diagnosis. Baseline questionnaires included the following: Modified Manchester Health Questionnaire, Fecal Incontinence Severity Index, Bristol Stool Scale, Pelvic Floor Distress Inventory, and the Pelvic Floor Impact Questionnaire.

RESULTS

Of the 133 women enrolled, 119 completed Rome III IBS questionnaires, and 111 reported on whether they had a previous diagnosis of IBS. The prevalence of IBS was 31% (95% confidence interval [CI], 22.9%-40.2%) according to the Rome III IBS criteria. The most common subtypes were IBS-mixed (41%) and IBS-diarrhea (35%). Twenty-four (22%) of 111 patients had a previous diagnosis of IBS. Among women who met Rome III IBS criteria, 23 (66%) of 35 women had never had a diagnosis of IBS. Women with FI and IBS reported significantly worse QOL compared to women without IBS despite similar FI severity and stool consistency.

CONCLUSIONS

Irritable bowel syndrome negatively affects QOL and affects one third of women with FI presenting for care in tertiary centers. Our findings suggest that assessment of IBS symptoms and diagnosis may be important for women presenting for FI treatment.

Validity of utility measures for women with pelvic organ prolapse

BACKGROUND

Pelvic organ prolapse is a common condition that frequently coexists with urinary and fecal incontinence. The impact of prolapse on quality of life is typically measured through condition-specific quality-of-life instruments. Utility preference scores are a standardized generic health-related quality-of-life measure that summarizes morbidity on a scale from 0 (death) to 1 (optimum health). Utility preference scores quantify disease severity and burden and are widely used in cost-effectiveness research. The validity of utility preference instruments in women with pelvic organ prolapse has not been established.

OBJECTIVE

The objective of this study was to evaluate the construct validity of generic quality-of-life instruments for measuring utility scores in women with pelvic organ prolapse. Our hypothesis was that women with multiple pelvic floor disorders would have worse (lower) utility scores than women with pelvic organ prolapse only and that women with all 3 pelvic floor disorders would have the worst (lowest) utility scores.

STUDY DESIGN

This was a prospective observational study of 286 women with pelvic floor disorders from a referral female pelvic medicine and reconstructive surgery practice. All women completed the following general health-related quality-of-life questionnaires: Health Utilities Index Mark 3, EuroQol, and Short Form 6D, as well as a visual analog scale. Pelvic floor symptom severity and condition-specific quality of life were measured using the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire, respectively. We measured the relationship between utility scores and condition-specific quality-of-life scores and compared utility scores among 4 groups of women: (1) pelvic organ prolapse only, (2) pelvic organ prolapse and stress urinary incontinence, (3) pelvic organ prolapse and urgency urinary incontinence, and (4) pelvic organ prolapse, urinary incontinence, and fecal incontinence.

RESULTS

Of 286 women enrolled, 191 (67%) had pelvic organ prolapse; mean age was 59 years and 73% were Caucasian. Among women with prolapse, 30 (16%) also had stress urinary incontinence, 39 (20%) had urgency urinary incontinence, and 42 (22%) had fecal incontinence. For the Health Utilities Index Mark 3, EuroQol, and Short Form 6D, the pattern in utility scores was noted to be lowest (worst) in the prolapse + urinary incontinence + fecal incontinence group (0.73-0.76), followed by the prolapse + urgency urinary incontinence group (0.77-0.85) and utility scores were the highest (best) for the prolapse only group (0.80-0.86). Utility scores from all generic instruments except the visual analog scale were significantly correlated with the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire total scores (r values -0.26 to -0.57), and prolapse, bladder, and bowel subscales (r values -0.16 to -0.50). Utility scores from all instruments except the visual analog scale were highly correlated with each other (r = 0.53-0.69, P < .0001).

CONCLUSION

The Health Utilities Index Mark 3, EuroQol, and Short Form 6D, but not the visual analog scale, provide valid measurements for utility scores in women with pelvic organ prolapse and associated pelvic floor disorders and could potentially be used for cost-effectiveness research.

Prevalence of anal incontinence in a working population within a healthcare environment

OBJECTIVES

Anal incontinence is a devastating affliction with several considerations that make it difficult to define in terms of epidemiology with good precision. The aim of the present work is to study the prevalence of an important disorder such as anal incontinence in a healthy working population within a sanitary environment.

MATERIAL AND METHODS

A cluster of easy understanding and filling inquiry forms are distributed to 910 apparently healthy individuals at our hospital. This questionnaires include filiation data, passed medical history, presence or not of Incontinence and other symptoms such as urgency. The Cleveland Clinic Incontinence Score is also registered.

RESULTS

Anal incontinence is present in a 21.2% of subjects when considered in any of it forms (flatus, liquid or solid faeces). A Clevleand Clinic Incontinence Score higher than 6 was obtained in a 7.3% of the sample and higher than 10 in 1.2%. No gender predominance has been identified. A slightly higher severity is recognised with increasing age. Obstetric and anal surgical background are the only related factors identified in the studied sample.

CONCLUSIONS

Faecal incontinence is a high prevalent affliction, even among apparently healthy population. Considering the aetiologic factors that have been established, prevention during obstetric and anal surgical procedures is absolutely mandatory.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Differences in innervated neurons of the internal anal sphincter based on age and sex: A histological study

AIM

Previous studies have shown sex and age differences in anal sphincter function, but few morphological studies have focused on the quality and quantity of the nerves that control the sphincter muscles. The present study aimed to determine whether there are morphological and quantitative sex and age differences in the nerves in the conjoined longitudinal muscle.

METHODS

This was a single-center, retrospective study using surgical specimens from 44 patients who underwent abdominoperineal resection between 2003 and 2012. Hematoxylin-eosin- and S-100-stained peripheral nerves (nerve fibers and ganglion cells) in the conjoined longitudinal muscle beneath the dentate line were observed microscopically. A qualitative examination assessed the degeneration score, which was based on the presence or absence of karyopyknosis, vacuolar degeneration, acidophilic degeneration of the cytoplasm, denucleation and adventitial neuronal changes. For quantitative examinations, each neuronal and muscular area was traced to calculate the neuronal area ratio in S-100-immunostained photomicrographs at the observation site.

RESULTS

Women had a significantly lower quantity of nerves than men. Older individuals (aged ≥80 years) had a significantly lower quantity of nerves than younger individuals. Furthermore, older individuals tended to show greater morphological changes that appeared to be a result of degeneration.

CONCLUSIONS

The present findings suggest that anal hypofunction in women and older individuals might result from differences in the quantity and quality of the neurons controlling the anal sphincter muscle. Geriatr Gerontol Int 2018; 18: 495-500.

Faecal incontinence: a narrative review of clinic-based management for the general gynaecologist

The objective of this article is to provide an informative and narrative review for the general Gynaecologist regarding the pathophysiology and conservative treatments available for faecal incontinence (FI). A PubMed search was performed by library staff and an author using the keywords: anal incontinence, faecal incontinence, accidental bowel leakage, outpatient clinic management of faecal incontinence and defecatory dysfunction. As the social limitations of FI can be devastating and long-term patient satisfaction rates after anal sphincteroplasty remain reportedly-low, the role of clinic-based management of FI has continued to grow. The purpose of this article is to provide the Obstetrician and Gynaecologist with a basic template for screening, evaluation and management of faecal incontinence in the clinical setting.

Efficacy of antibiotherapy for treating flatus incontinence associated with small intestinal bacterial overgrowth: A pilot randomized trial

Aim

An increase in intestinal gas production due to small intestinal bowel overgrowth (SIBO) is a contributing factor for flatus incontinence. The aims of our study were to assess the efficacy of metronidazole in a select population of patients with flatus incontinence associated with SIBO and to compare its efficacy with that of a combination of simethicone and activated charcoal (SC; Carbosylane) in randomized experimental arms.

Methods

Adult patients suffering from flatus incontinence associated with SIBO diagnosed by a glucose breath test were enrolled in the study. They were given metronidazole or Carbosylane (SC) for 10 days. The reduction in the mean daily number of gas leakages reported in a 3-day diary before and at the end of the treatment was used as the primary endpoint.

Results

Of 52 consecutive subjects with flatus incontinence, 23 (44%) had SIBO, 16 (33%) of whom were included in and completed the study. The relative reduction in flatus incontinence episodes was significantly higher in the metronidazole than in the SC group (66.8±34.8% vs. 25±50%, P = 0.03), decreasing by more than 50% in 7 (87.5%) of the subjects in the metronidazole group compared with only 1 (12.5%) in the SC group (odds ratio 1.9, 95% confidence interval 0.9–56.9, P = 0.06).

Conclusion

Our results show a promising trend indicating that metronidazole might significantly improve flatus incontinence associated with SIBO and might be more successful in treating flatus incontinence than gas absorbents.

Interview-based versus self-reported anal incontinence using St Mark's incontinence score

INTRODUCTION AND HYPOTHESIS

St Mark's incontinence score (SMIS) was originally designed and validated for use in an interview setting (iSMIS), and there is conflicting evidence for the validity of the self-administered SMIS (sSMIS). Our objective was to compare self-administered and interview-based reports of anal incontinence (AI) symptoms.

METHODS

A total of 147 women reported symptoms of AI on a sSMIS before inclusion in a clinical study investigating the effect of conservative treatment for AI 1 year after delivery. After clinical investigations, an iSMIS was completed by one of two consultant surgeons blinded to the sSMIS results. The correlation and agreement among the individual items of the iSMIS and the sSMIS were assessed using Spearman's rho and weighted kappa statistics, respectively.

RESULTS

The mean iSMIS and sSMIS reported was 4.0 (SD: 3.6) and 4.3 (SD: 4.0), respectively. Spearman's rho showed a strong relationship between the two total SMIS scores (r = 0.769, n = 147, p < 0.001), and explained variance was 59% (r²=0.591). Except for the individual item about gas incontinence, women reported more frequent AI symptoms on the sSMIS than on the iSMIS. The assessment of consistency among the individual items of the iSMIS and sSMIS showed substantial agreement (κ ≥ 0.60) for all items except for fair agreement for the item about formed stool incontinence (κ = 0.22), and moderate for the item about any change in lifestyle (κ = 0.5).

CONCLUSIONS

The level of consistency between the two methods of reporting anal incontinence symptoms suggests that the St Mark's score may be used as both an interview-based and a self-administered incontinence score.

Pathophysiology and Therapeutic Options for Fecal Incontinence

Fecal incontinence (FI), defined as the involuntary loss of solid or liquid feces through the anus is a prevalent condition with significant effects on quality of life. FI can affect individuals of all ages and in many cases greatly impairs quality of life but, incontinent patients should not accept their debility as either inevitable or untreatable. The severity of incontinence can range from unintentional elimination of flatus to the complete evacuation of bowel contents. It is reported to affect up to 18% of the population, with a prevalence reaching as high as 50% in nursing home residents. However, FI is often underreported, thus obscuring its true prevalence in the general population. The options for treatment vary according to the degree and severity of the FI. Treatment can include dietary and lifestyle modification, certain medications, biofeedback therapy, bulking agent injections, sacral nerve stimulation as well as various types of surgery. In this article, we aim to provide a comprehensive review on the diagnosis and management of FI.

Improving biofeedback for the treatment of fecal incontinence in women: implementation of a standardized multi-site manometric biofeedback protocol

BACKGROUND

Standardized training and clinical protocols using biofeedback for the treatment of fecal incontinence (FI) are important for clinical care. Our primary aims were to develop, implement, and evaluate adherence to a standardized protocol for manometric biofeedback to treat FI.

METHODS

In a Pelvic Floor Disorders Network (PFDN) trial, participants were enrolled from eight PFDN clinical centers across the United States. A team of clinical and equipment experts developed biofeedback software on a novel tablet computer platform for conducting standardized anorectal manometry with separate manometric biofeedback protocols for improving anorectal muscle strength, sensation, and urge resistance. The training protocol also included education on bowel function, anal sphincter exercises, and bowel diary monitoring. Study interventionists completed online training prior to attending a centralized, standardized certification course. For the certification, expert trainers assessed the ability of the interventionists to perform the protocol components for a paid volunteer who acted as a standardized patient. Postcertification, the trainers audited interventionists during trial implementation to improve protocol adherence.

KEY RESULTS

Twenty-four interventionists attended the in-person training and certification, including 46% advanced practice registered nurses (11/24), 50% (12/24) physical therapists, and 4% physician assistants (1/24). Trainers performed audio audits for 88% (21/24), representing 84 audited visits. All certified interventionists met or exceeded the prespecified 80% pass rate for the audit process, with an average passing rate of 93%.

CONCLUSIONS & INFERENCES

A biofeedback protocol can be successfully imparted to experienced pelvic floor health care providers from various disciplines. Our process promoted high adherence to a standard protocol and is applicable to many clinical settings.

Fecal Incontinence: Epidemiology, Impact, and Treatment

Fecal incontinence (FI) is a chronic and debilitating condition that carries a significant health, economic, and social burden. FI has a considerable psychosocial and financial impact on patients and their families. A variety of treatment modalities are available for FI including behavioral and dietary modifications, pharmacotherapy, pelvic floor physical therapy, bulking agents, anal sphincteroplasty, sacral nerve stimulation, artificial sphincters, magnetic sphincters, posterior anal sling, and colostomy.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Impact of fecal incontinence and its treatment on quality of life in women

Fecal incontinence (FI) is a physically and psychosocially debilitating disorder which negatively impacts quality of life (QOL). It bears a significant burden not only on patients but also on their families, caretakers as well as society as a whole. Even though it is considered a somewhat common condition, especially as women age, the prevalence is often underestimated due to patients' reluctance to report symptoms or seek care. The evaluation and treatment of FI can be also hindered by lack of understanding of the current management options among healthcare providers and how they impact on QOL. This article provides a comprehensive review on the impact of FI and its treatment on QOL in women.

The bother of anal incontinence and St. Mark's Incontinence Score

BACKGROUND

Patient self-report is important in the assessment of the impact of anal incontinence (AI) on quality of life. This study aimed to (1) determine the correlation between total St. Mark's Incontinence Score (SMIS) and a single-item visual analogue scale (VAS) for bother from AI, and (2) determine the correlation between individual components of SMIS and VAS.

METHODS

This is a retrospective study conducted on a cohort of 516 women seen for symptoms of lower urinary tract and pelvic floor dysfunction between January 2013 and August 2014. If a woman responded "yes" to the question "Do you experience any leakage from the back passage/anus?" they were considered to have AI, and the SMIS was administered. They were also asked "How much are you bothered by these symptoms?" to assess bother from AI by VAS. Statistical analyses were performed using Spearman's correlation and Mann-Whitney U test.

RESULTS

Eighty-four (16.3 %) women reported AI with a mean SMIS of 11 (SD ± 5.11, range 2-24) and median bother of 5 (VAS 1-10). There was a fair correlation between VAS for the bother from AI and SMIS (Spearman's r = 0.523, p < 0.001). Fecal urgency, impact on lifestyle, and use of pad/plug were significantly associated with VAS (p = 0.05, p = 0.002 and p < 0.001, respectively).

CONCLUSIONS

There is a fair, positive correlation between VAS for bother from AI and SMIS. Patients' bother from AI is strongly associated with its impact on lifestyle as quantified by individual SMIS components.

Standard compared with mnemonic counseling for fecal incontinence: a randomized controlled trial

OBJECTIVE

To estimate whether women who underwent mnemonic counseling had better recall of fecal incontinence therapies at 2 months and if mnemonic counseling resulted in greater satisfaction with physician counseling and improvement in quality of life when compared with a group who underwent standard counseling.

METHODS

Counseling-naive women with fecal incontinence were recruited from an academic urogynecology clinic. Women underwent physical examinations, completed the Quality of the Physician-Patient Interaction, recorded fecal incontinence treatment options they recalled, and completed the Fecal Incontinence Severity Index and Manchester Health Questionnaire immediately after counseling and again at 2 months.

RESULTS

Ninety women consented to participate, were randomized, and completed baseline questionnaires. At baseline, women did not differ in age, ethnicity, education, Fecal Incontinence Severity Index, or Manchester Health Questionnaire scores. After counseling, the mnemonic group reported higher satisfaction on Quality of the Physician-Patient Interaction (66.4±6.5 compared with 62.2±10.7, P=.03). Ninety percent (81/90) of women followed up at 2 months. Our primary endpoint, 2-month recall of fecal incontinence treatments, was not different between groups (2.3±1.6 mnemonic counseling compared with 1.8±1.0 standard counseling; P=.08). Secondary endpoints for the mnemonic group reported greater improvement on total Manchester Health Questionnaire (P=.02), emotional (P=.03), sleep (0.045), role limitations (P<.01), and physical limitations (P=.04) when compared with the standard group.

CONCLUSION

Fecal incontinence counseling with a mnemonic aid did not improve recall at 2 months but improved patient satisfaction and quality of life at 2 months.

The relationship of 3-D translabial ultrasound anal sphincter complex measurements to postpartum anal and fecal incontinence

INTRODUCTION AND HYPOTHESIS

We aimed to determine whether anal sphincter complex (ASC) measurements on translabial ultrasound (TL-US) were related to anal incontinence (AI) or fecal incontinence (FI) symptoms 6 months postpartum.

METHODS

A prospective cohort of primiparous women underwent TL-US 6 months after a vaginal birth (VB) or cesarean delivery (CD). Muscle thickness was measured at 3, 6, 9, and 12 o'clock positions of the external anal sphincter (EAS), the same four quadrants of the internal anal sphincter (IAS) at proximal, mid, and distal levels, and at the bilateral pubovisceralis muscle (PVM). Measurements were correlated to AI and FI on the Wexner Fecal Incontinence Scale, with sub-analyses by mode of delivery. The odds ratio (OR) of symptoms was calculated for every 1 mm increase in muscle thickness (E1MIT).

RESULTS

A total of 423 women (299 VB, 124 CD) had TL-US 6 months postpartum. Decreased AI risk was associated with thicker measurements at the 6 o'clock (OR 0.74 E1MIT) and 9 o'clock proximal IAS (OR 0.71 E1MIT) in the entire cohort. For CD women, thicker measurements of the 9 o'clock proximal IAS were associated with decreased risk of AI (OR 0.56 E1MIT) and thicker distal 6 o'clock IAS measurements were related to a decreased risk of FI (OR 0.37 E1MIT). For VB women, no sphincter measurements were significantly related to symptoms, but thicker PVM measurements were associated with increased risk of AI (right side OR 1.32 E1MIT; left side OR 1.21 E1MIT).

CONCLUSIONS

ASC anatomy is associated with AI and FI in certain locations; these locations vary based on the patient's mode of delivery.

Epidemiology, pathophysiology, and classification of fecal incontinence: state of the science summary for the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) workshop

In August 2013, the National Institutes of Health sponsored a conference to address major gaps in our understanding of the epidemiology, pathophysiology, and management of fecal incontinence (FI) and to identify topics for future clinical research. This article is the first of a two-part summary of those proceedings. FI is a common symptom, with a prevalence that ranges from 7 to 15% in community-dwelling men and women, but it is often underreported, as providers seldom screen for FI and patients do not volunteer the symptom, even though the symptoms can have a devastating impact on the quality of life. Rough estimates suggest that FI is associated with a substantial economic burden, particularly in patients who require surgical therapy. Bowel disturbances, particularly diarrhea, the symptom of rectal urgency, and burden of chronic illness are the strongest independent risk factors for FI in the community. Smoking, obesity, and inappropriate cholecystectomy are emerging, potentially modifiable risk factors. Other risk factors for FI include advanced age, female gender, disease burden (comorbidity count, diabetes), anal sphincter trauma (obstetrical injury, prior surgery), and decreased physical activity. Neurological disorders, inflammatory bowel disease, and pelvic floor anatomical disturbances (rectal prolapse) are also associated with FI. The pathophysiological mechanisms responsible for FI include diarrhea, anal and pelvic floor weakness, reduced rectal compliance, and reduced or increased rectal sensation; many patients have multifaceted anorectal dysfunctions. The type (urge, passive or combined), etiology (anorectal disturbance, bowel symptoms, or both), and severity of FI provide the basis for classifying FI; these domains can be integrated to comprehensively characterize the symptom. Several validated scales for classifying symptom severity and its impact on the quality of life are available. Symptom severity scales should incorporate the frequency, volume, consistency, and nature (urge or passive) of stool leakage. Despite the basic understanding of FI, there are still major knowledge gaps in disease epidemiology and pathogenesis, necessitating future clinical research in FI.

Management of pelvic floor disorders: biofeedback and more

OPINION STATEMENT

Defecatory disorders (DD) and fecal incontinence (FI) are common conditions. DD are primarily attributable to impaired rectoanal function during defecation or structural defects. FI is caused by one or more disturbances of anorectal continence mechanisms. Altered stool consistency may be the primary cause or may unmask anorectal deficits in both conditions. Diagnosis and management requires a systematic approach beginning with a thorough clinical assessment. Symptoms do not reliably differentiate a DD from other causes of constipation such as slow or normal transit constipation. Therefore, all constipated patients who do not adequately respond to medical therapy should be considered for anorectal testing to identify a DD. Preferably, two tests indicating impaired defecation are required to diagnose a DD. Patients with DD, or those for whom testing is not available and the clinical suspicion is high, should be referred for biofeedback-based pelvic floor physical therapy. Patients with FI should be managed with lifestyle modifications, pharmacotherapy for bowel disturbances, and management of local anorectal problems (e.g., hemorrhoids). When these measures are not beneficial, anorectal testing and pelvic floor retraining with biofeedback therapy should be considered. Sacral nerve stimulation or perianal bulking could be considered in patients who have persistent symptoms despite optimal management of bowel disturbances and pelvic floor retraining.

Obstetrics and fecal incontinence

Anal incontinence (AI) can be a debilitating condition for women following vaginal delivery. Operative vaginal delivery and anal sphincter laceration are important risk factors for the development of postpartum AI. Obtaining a comprehensive delivery history, along with a thorough physical examination of the perineum, vagina and rectum may aid the clinician in the diagnosis of an anal sphincter defect. Sonographic imaging can also assist in identifying sphincter defects. The treatment of AI may include a combination of dietary modification, medications that promote constipation, pelvic floor physical therapy, biofeedback, anal sphincteroplasty, and/or sacral neuromodulation.

Obstetrics and fecal incontinence

Anal incontinence (AI) can be a debilitating condition for women following vaginal delivery. Operative vaginal delivery and anal sphincter laceration are important risk factors for the development of postpartum AI. Obtaining a comprehensive delivery history, along with a thorough physical examination of the perineum, vagina and rectum may aid the clinician in the diagnosis of an anal sphincter defect. Sonographic imaging can also assist in identifying sphincter defects. The treatment of AI may include a combination of dietary modification, medications that promote constipation, pelvic floor physical therapy, biofeedback, anal sphincteroplasty, and/or sacral neuromodulation.

Anal incontinence: long-term alterations in the incidence and healthcare usage

OBJECTIVE

The aim of the study was to determine the alterations in the occurrence of incontinence and how subjects suffering from incontinence seek and receive healthcare services over a 10-year follow-up period.

METHODS

Postal questionnaires (Wexner Incontinence Score, Fecal Incontinence Quality of Life Scale, a questionnaire to investigate the management of fecal incontinence and the frequency of urinary incontinence) were sent to subjects who had reported anal incontinence in our population-based study in 2003. For each incontinent person (n = 155) from the 2003 series, we identified two control subjects (n = 310) who did not suffer from incontinence.

RESULTS

Of the initially incontinent, 47 (58%) had remained incontinent after a follow up of 10 years. Almost 80% of the incontinent subjects in 2012 were female. Of the 152 initially continent, 12 (7.9%) had developed symptoms, all of whom were females. Urinary incontinence was present in approximately 60% of incontinent subjects. The majority (57.8%) of the subjects still incontinent in 2012 felt that they needed help for the complaint, but only 30.9% had received any, and only 7.4% received any benefit. The most common treatment was medication. The subjective incontinence impaired the quality of life.

CONCLUSION

Incontinence is a chronic long-lasting disorder. The current management of anal incontinence is not satisfactory. The primary healthcare system should be more aware of the nature of this condition to find and offer treatment for the patients.