Recommendations on the management of pudendal nerve entrapment syndrome: A formalised expert consensus

BACKGROUND

Since the development and publication of diagnostic criteria for pudendal nerve entrapment (PNE) syndrome in 2008, no comprehensive work has been published on the clinical knowledge in the management of this condition. The aim of this work was to develop recommendations on the diagnosis and the management of PNE.

METHODS

The methodology of this study was based on French High Authority for Health Method for the development of good practice and the literature review was based on the PRISMA method. The selected articles have all been evaluated according to the American Society of Interventional Pain Physicians assessment grid.

RESULTS

The results of the literature review and expert consensus are incorporated into 10 sections to describe diagnosis and management of PNE: (1) diagnosis of PNE, (2) patients advice and precautions, (3) drugs treatments, (4) physiotherapy, (5) transcutaneous electrostimulations (TENS), (6) psychotherapy, (7) injections, (8) surgery, (9) pulsed radiofrequency, and (10) Neuromodulation. The following major points should be noted: (i) the relevance of 4+1 Nantes criteria for diagnosis; (ii) the preference for initial monotherapy with tri-tetracyclics or gabapentinoids; (iii) the lack of effect of opiates, (iv) the likely relevance (pending more controlled studies) of physiotherapy, TENS and cognitive behavioural therapy; (v) the incertitudes (lack of data) regarding corticoid injections, (vi) surgery is a long term effective treatment and (vii) radiofrequency needs a longer follow-up to be currently proposed in this indication.

CONCLUSION

These recommendations should allow rational and homogeneous management of patients suffering from PNE. They should also allow to shorten the delays of management by directing the primary care.

SIGNIFICANCE

Pudendal nerve entrapment (PNE) has only been known for about 20 years and its management is heterogeneous from one practitioner to another. This work offers a synthesis of the literature and international experts' opinions on the diagnosis and management of PNE.

Perineal retraining improves conservative treatment for faecal incontinence: a multicentre randomized study

BACKGROUND

Anal incontinence is a frequent complaint that profoundly affects quality of life. Our aim was to determine whether perineal retraining gives additional benefits to standard medical treatment.

METHODS

Patients with anal incontinence and a Wexner score >4 were randomly assigned to standard conservative treatment (control) or perineal retraining, including biofeedback, in addition to standard treatments (biofeedback). Diaries, self-administered questionnaires and satisfaction scores quantified the benefits. Self-evaluated improvement was the primary outcome measure. A score ≥3 (in an improvement scale from -5 to +5) defined success.

RESULTS

Overall, 157 patients were included; 80 in the control group (75% females, mean age 60.1 ± 13.2 years) and 77 in the biofeedback group (79% females, mean age 61.9 ± 10.2 years). After a 4-month follow-up, the success rate was significantly higher in the biofeedback group (57% versus 37%; p<0.021). In the biofeedback group, daily stool frequency, leakage, and faecal urgency significantly decreased, and daily non-urgent perception of stool increased. Conversely, symptomatic scores and quality of life scales did not significantly differ between groups. In a multivariate model, the adjusted odds ratio showed that perineal retraining was significantly associated with a higher chance of self-rated improvement (adjusted Odd Ratio [95%CI]: 2.34 [1.14-4.80]; p=0.021).

CONCLUSIONS

Perineal retraining offers a moderate but significant benefit for patients suffering from anal incontinence.

Clinical characteristics and quality of life in a cohort of 621 patients with faecal incontinence

AIM

The aim of this study was to study a cohort of patients with faecal incontinence (FI) to gain a better insight into the clinical and epidemiological characteristics of this pathology and its repercussions on quality of life (QL).

MATERIALS AND METHODS

Consecutive patients with FI seen at tertiary centres filled in a self-questionnaire. The severity of FI, constipation and urinary incontinence (UI) was evaluated, respectively, by the Jorge and Wexner score, the Knowles-Eccersley-Scott Symptom score and the Urological Distress Inventory score. ROME II criteria were used to assess the existence of an associated irritable bowel syndrome. The repercussion on QL was evaluated by the Gastrointestinal Quality of Life index score and the Ditrovie score. The psychological status was assessed by the Hospital Anxiety and Depression scale.

RESULTS

Six hundred twenty-one patients (114 men), mean age 58 +/- 15 years (range: 20-92), with FI, filled in the questionnaire. The mean Jorge and Wexner score was 11 +/- 4. Twenty-seven presented with an irritable bowel syndrome. Thirty-eight percent had an associated constipation. A UI was associated in 48% women and 25% men. QL was significantly altered, and anxiety and depression were frequent.

CONCLUSIONS

FI symptoms are frequently severe, QL very altered and anxiety and depression common. FI is frequently associated with other digestive and perineal symptoms, which argue in favour of a multi-disciplinary management of FI.

Prevalence of anal incontinence in adults and impact on quality-of-life

OBJECTIVE

To investigate the prevalence of anal incontinence in the general population and in patients consulting gastroenterologist and gynecologist practices in the Rhône Alpes area.

METHODS

For the first study a questionnaire was sent to a sample of 2800 people selected randomly from the electoral roll. Another study of patients selected randomly among patients attending gynecology and gastroenterology consultations was performed. A Jorge & Wexner score above or equal to 5 was used to define anal incontinence.

RESULTS

For the first study, a total of 706 questionnaires was analyzed: the prevalence of anal incontinence was 5.1% [95% CI: 3.6-7.0] and the scores of each dimension of the SF-12 Health Survey were significantly lower among incontinent people than among continent people. The prevalence was significantly higher for women (7.5% [5.0-10.7]) than for men (2.4% [1.1-4.7]). Eighty-four physicians returned 835 valid questionnaires. The prevalence was 13.1% [10.1-16.6] among patients attending gastroenterology consultations and 5.0% [3.1-7.6] among those attending gynecology consultations. For 84.8% of the incontinent patients, the physician was unaware of the patient's disorder.

CONCLUSION

The prevalence figures we obtained coincide with data in the literature. This disorder is common and affects the patient's quality-of-life, but remains underestimated and under-diagnosed.

[Rehabilitation during pregnancy and in the postpartum]

Pregnancy and labour are notable etiopathogenic factors concerning urinary incontinence and pelvic positional problems. 30 to 40% of women suffer from incontinence during pregnancy and 20% in the post-partum period. While this incontinence regresses spontaneously in 60 to 80% of cases, it nevertheless reflects the existence of pelviperineal problems. Combined with the efforts of everyday life, this trauma finally explains the high incidence of women with urinary problems and pelvic positional difficulties starting from the fourth and fifth decades of life. Perineo-sphincter exercises must be started very early, during the pre-partum phase and always before the start of sports and occupational activities. It involves all the constituents of the lumbo-pelvi-perineal region and in particular perineal tone, muscle power and strength and the quality of sphincter closure during effort. These efforts are themselves studied on the basis of the pressures which they produce. In total, perineal exercises, abdominal exercises and physical activity are not contradictory but, in fact, complementary, such that the management approach is global and adapted to the individual.

[Terminal constipation caused by abdominopelvic asynchrony: analysis of etiological, clinical, manometric data and therapeutic results after rehabilitation by biofeedback]

The aim of this study was to describe the etiological, clinical, rectoanal manometric findings as well as the results of biofeedback therapy in a series of 65 patients (34 males, 31 females, aged between 5 and 77 years) presenting with severe primary constipation due to pelvic abdominal asynchronism. Pelvic abdominal asynchronism was statistically more frequent in males during childhood and in female patients during adult life (p less than 0.005). This study disclosed a high frequency of psychogenic factors in the onset of pelvic abdominal asynchronism (26 p. 100) as well as a high frequency of soiling (46.2 p. 100) in constipated patients. In 36.2 p. 100 of cases, pelvic abdominal asynchronism was the only abnormality. In contrast, in most of the patients, asynchronism was associated with miscellaneous rectoanal disorders: increased anal closure pressure (43.3 p. 100), decreased anal closure pressure (11.8 p. 100), impaired rectal conscious sensitivity (11.7 p. 100), and increased rectal compliance (31 p. 100). This study demonstrated that when high-fiber diet and laxatives fail, biofeedback therapy is a very interesting alternative, providing 80 p. 100 of good results in selected cases. However, we were unable to find any clinical or manometric parameters predictive of results of treatment. Follow-up studies are needed to determine long-term results of biofeedback training.