Assessing Anorectal Function in Constipation and Fecal Incontinence

Constipation and fecal incontinence are commonly encountered complaints in the gastrointestinal clinic. Assessment of anorectal function includes comprehensive history, rectal examination, and prospective stool diary or electronic App diary that accurately captures bowel symptoms, evaluation of severity, and quality of life of measure. Evaluation of a suspected patient with dyssynergic constipation includes anorectal manometry, balloon expulsion test, and defecography. Investigation of a suspected patient with fecal incontinence includes high-resolution anorectal manometry; anal ultrasound or MRI; and neurophysiology tests, such as translumbosacral anorectal magnetic stimulation or pudendal nerve latency. This article provides an approach to the assessment of anorectal function.

Pelvic floor rehabilitation to improve functional outcome and quality of life after surgery for rectal cancer: study protocol for a randomized controlled trial (FORCE trial)

BACKGROUND

After low anterior resection (LAR), up to 90% of patients develop anorectal dysfunction. Especially fecal incontinence has a major impact on the physical, psychological, social, and emotional functioning of the patient but also on the Dutch National Healthcare budget with more than €2000 spent per patient per year. No standardized treatment is available to help these patients. Common treatment nowadays is focused on symptom relief, consisting of lifestyle advices and pharmacotherapy with bulking agents or antidiarrheal medication. Another possibility is pelvic floor rehabilitation (PFR), which is one of the most important treatments for fecal incontinence in general, with success rates of 50-80%. No strong evidence is available for the use of PFR after LAR. This study aims to prove a beneficial effect of PFR on fecal incontinence, quality of life, and costs in rectal cancer patients after sphincter-saving surgery compared to standard treatment.

METHODS

The FORCE trial is a multicenter, two-armed, randomized clinical trial. All patients that underwent LAR are recruited from the participating hospitals and randomized for either standard treatment or a standardized PFR program. A total of 128 patients should be randomized. Optimal blinding is not possible. Stratification will be done in variable blocks (gender and additional radiotherapy). The primary endpoint is the Wexner incontinence score; secondary endpoints are health-related and fecal-incontinence-related QoL and cost-effectiveness. Baseline measurements take place before randomization. The primary endpoint is measured 3 months after the start of the intervention, with a 1-year follow-up for sustainability research purposes.

DISCUSSION

The results of this study may substantially improve postoperative care for patients with fecal incontinence or anorectal dysfunction after LAR. This section provides insight in the decisions that were made in the organization of this trial.

TRIAL REGISTRATION

Netherlands Trial Registration, NTR5469, registered on 03-09-2015. Protocol FORCE trial V18, 19-09-2019. Sponsor Radboud University Medical Center, Nijmegen.

Rehabilitation and reintegration programming adjunct to female genital fistula surgery: a scoping review protocol

INTRODUCTION

Female genital fistula is a debilitating traumatic injury, largely birth-associated, globally affecting up to 2 million women, mostly in sub-Saharan Africa. Fistula has significant physical, psychological and economic consequences. Women often face challenges in reintegrating and resuming prior roles despite successful surgery. Synthesising the evidence on services adjunct to fistula surgery and their outcomes is important for developing the evidence base for best practices and identifying research priorities. This scoping review seeks to examine the range of rehabilitation and reintegration services provided as adjunct to genital fistula surgery, map the existing programming and outcomes, and identify areas for additional research.

METHODS AND ANALYSIS

Our scoping review is informed by existing methodological frameworks and will be conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses-ScR guidelines. The search strategy will be applied to nine biomedical, public health and social science databases. The initial search was completed on 27 September 2018. Grey literature will be identified through targeted Google searches and from organisational websites identified as relevant by the United Nations Population Fund (UNFPA) Campaign to End Fistula. We will iteratively build our search strategy through term harvesting and review, and search reference lists of reports and articles to identify additional studies. Two reviewers will independently screen titles and abstracts, followed by full-text screening of all potentially relevant articles and standardised data extraction. Articles eligible for inclusion will discuss research or programmatic efforts around service provision in adjunct to surgery among females with genital fistula. Data will be presented in summary tables accompanied by narrative description.

ETHICS AND DISSEMINATION

Ethics approval is not required for a scoping review. Our results can be used to inform policy, serve as support for funding and development of reintegration programmes and highlight areas for subsequent research. Results will be disseminated at relevant conferences and published in a peer-reviewed journal.

Urinary and faecal incontinence: psychological factors and management recommendations

BACKGROUND

Urinary and faecal incontinence substantially impacts upon physical health and is associated with significant psychological distress and reduced quality of life. Due to stigma and embarrassment, many patients do not present for management of their incontinence.

AIM

The objective of this article is to summarise the forms and causes of urinary and faecal incontinence, highlight the psychological mechanisms and psychopathology associated with incontinence, and provide management recommendations.

CONCLUSION

Urinary and faecal incontinence can have a significant impact on an individual's psychological wellbeing and quality of life. Psychological factors may either contribute to or arise from incontinence and should be addressed as part of the overall management plan.

Preferences for Continence Care Experienced at End of Life: A Qualitative Study

CONTEXT

Functional dependence at end of life often leaves individuals requiring help for personal care, including maintaining continence. Current continence guidelines offer little direction for end of life continence care, and little is known of the perspectives of people receiving palliative care.

OBJECTIVES

The aim of the study was to examine the continence care preferences of people receiving palliative care to understand what approaches to care and what goals of care are important to them.

METHODS

This is a qualitative descriptive exploratory study with data gathered in individual interviews using a semi-structured interview guide. Participants were receiving bladder and/or bowel care on either tertiary or hospice palliative care units.

RESULTS

Fourteen Canadian patients (seven female, seven male), six from tertiary and eight from hospice palliative care units, were recruited. From the analysis, three themes were identified: loss of control, finding a way to manage, and caregivers can help and can hinder. Dignity was often lost as a result of having to receive continence care, with most participants following staff recommendations for management approaches as the easiest way. Patients did not recall being asked about their bladder and bowel preferences.

CONCLUSIONS

As patients approached end of life they were willing to give up dignity if it was required to address symptoms causing them more distress, like pain. Health care professionals and family have an important role in social interactions around continence care. Health care professionals should incorporate patient preferences as best they can and explain the options when treating incontinence at end of life.

Fecal urgency is common in constipated patients and is associated with anxiety

BACKGROUND

Fecal urgency is a symptom generally associated with diarrhea but is also reported by patients with constipation. Our aim was to (a) assess the prevalence and burden of fecal urgency in constipated patients (b) evaluate gastrointestinal and psychiatric predictors of moderate to severe fecal urgency in these patients.

METHODS

Patients presenting consecutively to a tertiary outpatient gastroenterology clinic with constipation were included. Patients were considered to have moderate to severe fecal urgency if ≥50% of bowel movements (BMs) in the past 3 months were associated with fecal urgency. Anxiety, depression, and sleep disturbance were diagnosed using a Patient-Reported Outcomes Measurement Information System (PROMIS) t-score of ≥60. Abdominal pain and constipation severity were also assessed using PROMIS questionnaires. Univariable and stepwise logistic regression were used to identify predictors of moderate to severe fecal urgency.

KEY RESULTS

Of 139 constipated patients, 70.8% reported experiencing fecal urgency in the past 3 months and 25.8% reported being significantly bothered by it. Moderate to severe fecal urgency was reported by 27% of 139 patients. Frequency of loose stools (OR 1.5, 95% CI 1.1, 2.0) and presence of anxiety (OR 2.3, 95% CI 1.1, 5.0) were independent predictors of moderate to severe fecal urgency.

CONCLUSIONS AND INFERENCES

Fecal urgency is common in patients with constipation and is frequently bothersome to many patients. We identified clinical and psychiatric factors associated with moderate to severe fecal urgency in constipated patients with potential therapeutic implications if validated in future studies.

Psychosocial risks for constipation and soiling in primary school children

To examine prospective associations between psychosocial problems and childhood constipation and soiling. We used latent classes of constipation and soiling ('constipation alone', 'soiling alone', 'constipation with soiling') extracted from longitudinal maternally reported data on constipation (4-10 years) and soiling (4-9 years) from 8435 children (4353 males, 4082 females) from the ALSPAC cohort. We examined the association between maternally reported psychosocial problems at 2-3 years (difficult temperament, behaviour/emotional problems, temper tantrums, behavioural sleep problems and stressful events) and the latent classes using multinomial logistic regression adjusted for a range of confounders relating to the child and family (reference category = normative latent class with very low probability of constipation/soiling). Difficult temperament and emotional/behaviour problems were associated with increased odds of constipation and soiling. Associations were generally strongest for 'constipation with soiling', e.g. difficult mood: 1.42 (1.23-1.64); behaviour problems: 1.48 (1.28-1.71); temper tantrums: 1.89 (1.34-2.65); lack of a regular sleep routine 2.09 (1.35-3.25). Stressful life events were associated with constipation alone [1.23 (1.12-1.36)] and constipation with soiling [1.32 (1.14-1.52)], but not soiling alone. Additional comparisons of the non-normative latent classes provided evidence for differential associations with the risk factors, e.g. frequent temper tantrums were associated with a greater than twofold increase in the odds of constipation with soiling versus constipation alone. Psychosocial problems in early childhood are risk factors for constipation and soiling at school age. An increased understanding of early risk factors for constipation and soiling could aid the identification of children who require treatment.

Clinical and psychological correlates of soiling in adult patients with functional gastrointestinal disorders

BACKGROUND/AIMS

Fecal soiling (FS) is the staining of underwear without loss of significant amounts of fecal material. It is frequently associated with defecation disorders in children. The aim of this study was to search for psychological and clinical correlates of adult patients with soiling. Clinically, the complaint of staining is confused with that of fecal incontinence (FI) in the mind of both patients and attending physicians.

DESIGN

Observational study PATIENTS AND METHOD: We included 1454 consecutive outpatients (71% females). They filled out the Rome III questionnaire for functional gastrointestinal disorders (FGIDs); Beck depression inventory, and state and trait anxiety questionnaires; and Likert scales for constipation, diarrhea, bloating, and abdominal pain. Data were analyzed using ANOVA and logistic regression analysis.

RESULTS

Soiling was found in 123 patients (8.5%). They reported similar frequencies of esophageal, gastroduodenal, and abdominal pain as patients without soiling. In contrast, patients with soiling reported higher prevalence of IBS, such as IBS-Diarrhea, Mixed-IBS, functional diarrhea, functional constipation, and levator ani syndrome, and higher Likert scale for diarrhea, bloating, abdominal pain, and softer stools. The multivariable logistic regression analysis shows that patients with soiling have increased odds to report IBS (P = 0.019; OR = 1.958; 95% CI = [1.118-3.431]), functional diarrhea (P = 0.040; OR = 1.901; 95% CI = [1.028-3.513]), and high Diarrhea Likert scale (P < 0.001; OR = 1.215; 95% CI = [1.130-1.306]). No association was found with psychological evaluation.

CONCLUSION

In FGID patients, soiling is not associated with psychological disorders and is mainly associated with IBS and functional diarrhea.

Bowel Dysfunction in Spinal Cord Injury

PURPOSE OF REVIEW

To evaluate and report current evidence regarding the management of bowel dysfunction in spinal cord injury. There is a paucity of high-quality large studies on which to base management advice.

RECENT FINDINGS

Recent research has focused on defining the nature of symptomatology of bowel dysfunction in SCI and describing the effects on quality of life and social interactions. Technical aspects of colonoscopy have received attention, and aspects of understanding the pathophysiology in relation to both neural and non-neural dysfunction have been studied. There has been refinement and expansion of the pharmacological and non-pharmacological treatment options for bowel dysfunction in SCI. Management of bowel dysfunction in SCI requires a comprehensive and individualized approach, encompassing lifestyle, toileting routine, stimulation, diet, medications, and surgery. Further high-quality research is required to inform best practice.

Does the Internet provide patients or clinicians with useful information regarding faecal incontinence? An observational study

BACKGROUND

The Internet has become an important platform for information communication. This study aim to investigate the utility of social media and search engines to disseminate faecal incontinence information.

METHODS

We looked into Social media platforms and search engines. There was not a direct patient recruitment and any available information from patients was already on public domain at the time of search. A quantitative analysis of types and volumes of information regarding faecal incontinence was made.

RESULTS

Twelve valid pages were identified on Facebook: 5 (41%) pages were advertising commercial incontinence products, 4 (33%) pages were dedicated to patients support groups and 3 (25%) pages provided healthcare information. Also we found 192 Facebook posts. On Twitter, 2890 tweets were found of which 51% tweets provided healthcare information; 675 (45%) were sent by healthcare professionals to patients, 530 tweets (35.3%) were between healthcare professionals, 201 tweets (13.4%) were from medical journals or scientific books and 103 tweets (7%) were from hospitals or clinics with information about events and meetings. The second commonest type of tweets was advertising commercial incontinence products 27%. Patients tweeted to exchange information and advice between themselves (20.5%). In contrast, search engines as Google/Yahoo/Bing had a higher proportion of healthcare information (over 70%).

CONCLUSION

Internet appears to have potential to be a useful platform for patients to learn about faecal incontinence and share information; however, given one lack of focus of available data, patients may struggle to identify valid and useful information.

"I am a person but I am not a person": experiences of women living with obstetric fistula in the central region of Malawi

BACKGROUND

The consequences of living with obstetric fistula are multifaceted and very devastating for women, especially those living in poor resource settings. Due to uncontrollable leakages of urine and/or feces, the condition leaves women with peeling of skin on their private parts, and the wetness and smell subject them to stigmatization, ridicule, shame and social isolation. We sought to gain a deeper understanding of lived experiences of women with obstetric fistula in Malawi, in order to recommend interventions that would both prevent new cases of obstetric fistula as well as improve the quality of life for those already affected.

METHODS

We conducted semi-structured interviews with 25 women with obstetric fistula at Bwaila Fistula Care Center in Lilongwe and in its surrounding districts. We interviewed twenty women at Bwaila Fistula Care Center; five additional women were identified through snowball sampling and were interviewed in their homes. We also interviewed twenty family members. To analyze the data, we used thematic analysis. Data were categorized using Nvivo 10. Goffman's theory of stigma was used to inform the data analysis.

RESULTS

All the women in this study were living a socially restricted and disrupted life due to a fear of involuntary disclosure and embarrassment. Therefore, "anticipated" as opposed to "enacted" stigma was especially prevalent among the participants. Many lost their positive self-image due to incontinence and smell. As a way to avoid shame and embarrassment, these women avoided public gatherings; such as markets, church, funerals and weddings, thus losing part of their social identity. Participants had limited knowledge about their condition.

CONCLUSION

The anticipation of stigma by women in this study consequently limited their social lives. This fear of stigma might have arisen from previous knowledge of social norms concerning bowel and bladder control, which do not take into account an illness like obstetric fistula. This misconception might have also arisen from lack of knowledge about causes of the condition itself. There is need therefore to create awareness and educate women and their communities about the causes of obstetric fistula, its prevention and treatment, which may help to prevent fistula as well as reduce all dimensions of stigma, and consequently increase dignity and quality of life for these women.

Reliability and validity of the Bladder and Bowel Dysfunction Questionnaireamong Turkish children

Background/aim: We developed a Turkish version of the Bladder and Bowel Dysfunction Questionnaire (BBDQ) and evaluated its psychometric properties among Turkish pediatric patients.Materials and methods: The BBDQ was translated into Turkish and then it was back-translated into English. A total of 193 patients were asked to complete the Turkish version of the BBDQ as well as the Dysfunctional Voiding and Incontinence Scoring System (DVISS). In addition, 39 children completed the same questionnaires twice at 2-week intervals for test/retest evaluation.Results: Cronbach's alpha coefficient of the BBDQ was 0.727. Reliability of the test/retest was 0.759 (P < 0.001). Area under the curve of the receiver operating characteristic plot was 0.765. There were statistically significant differences in BBDQ scores between the controls and patients (P < 0.001). Analysis demonstrated moderate convergent validity against the DVISS (r: 0.78, r2: 0.601, P < 0.0001).Conclusion: The Turkish version of the BBDQ is a reliable and valid instrument for Turkish pediatric patients with bladder and bowel dysfunction in clinical and research settings.

Empirically Derived Patterns of Pain, Stooling, and Incontinence and Their Relations to Health-Related Quality of Life Among Youth With Chronic Constipation

Objective

Chronic constipation is associated with pain, stress, and fecal incontinence, which negatively impact health-related quality of life (HRQoL); however, it is unclear if patterns of pain, stool frequency, and incontinence are differentially associated with HRQoL in youth with chronic constipation.

Methods

410 caregivers completed a demographics and symptoms form, the Parental Opinions of Pediatric Constipation, Pediatric Symptom Checklist, and the Functional Disability Inventory.

Results

Stooling patterns were derived using Latent Variable Mixture Modeling. A three-class model emerged: withholding/avoiding ( WA ), pain , and fecal incontinence ( FI ). The pain class reported the greatest amount of disease burden/distress, greatest impairments in illness-related activity limitations, more psychosocial problems, and, along with the FI class, elevated levels of family conflict. The FI class reported the greatest amount of parental worry of social impact.

Conclusions

Youth with chronic constipation who experience pain or fecal incontinence may be at a greater risk for specific HRQoL problems such as illness-related activity limitations, psychosocial issues, disease burden and worry, and family conflict.

'What does that mean?': a qualitative exploration of the primary and secondary clinical care experiences of young people with continence problems in the UK

OBJECTIVES

To explore the clinical care experiences of young people with continence problems.

DESIGN

In-depth semistructured qualitative interviews were conducted by Skype and telephone, with the addition of art-based participatory research techniques. Transcripts were analysed using inductive thematic analysis.

SETTING

Primary and secondary care in the UK.

PARTICIPANTS

We interviewed 20 participants (9 females, 11 males) aged 11-20 years. There were six participants with bedwetting alone, five with daytime wetting alone, five with combined (day and night) wetting and four with soiling.

RESULTS

We identified four themes: appointment experiences, treatment experiences, engagement with treatment and internalisation and externalisation of the continence problem. Patient-focused appointments using age-appropriate language were highly desirable. Continuity of care was highlighted as an important aspect of positive clinical experiences; however, this was found to be rare with many participants seeing a different person on each visit. Participants had tried a wide range of treatments for their continence problems with varying degrees of success. Relapse and treatment failure were common. Experiencing relapse was distressing and diminished participants' belief in the success of future treatments and undermined adherence. Participants would be seen to adopt two opposing coping strategies for dealing with their continence problem- internalisation and externalisation.

CONCLUSION

Incontinence in young people is challenging to manage. Young people may need to try a range of treatments before their symptoms improve. Due to challenges in treatment, there is an increased risk of poor adherence. During patient-focused appointments, clinicians should work to build rapport with patients and use age-appropriate language. Involving young people in their own care decisions is important. The way in which young people understand their continence problem can influence their coping strategies and adherence to treatment regimes.

Delayed Reconstruction of a Traumatic Cloaca Following Obstetric Anal Sphincter Rupture

Permanent communication between the rectum and the vagina along with full thickness of anal sphincter faults can be a result of an unsuccessful primary repair of fourth degree obstetric trauma. This results into complete fecal incontinence and impaired quality of life. Anterior overlapping sphincteroplasty can be chosen as a method of treatment for fecal incontinence due to obstetric injuries. However, large perineal body reconstructions are generally pretty challenging tasks for surgeons. What we will describe here for the repair of a traumatic cloaca, occurred 23 years ago during vaginal delivery, is the use of a transpositional flap following overlapping sphincteroplasty. Anatomic recovery and fecal continence restoration have been accomplished completely by a follow-up of 24 months.

[Restorative proctocolectomy for ulcerative colitis : Long-term functional results and quality of life]

Restorative proctocolectomy with ileo-pouch-anal anastomosis is the standard procedure for ulcerative colitis. It provides complete removal of the diseased colorectum, avoids permanent ileostomy and allows the preservation of continence. Functional results and quality of life after restorative proctocolectomy are of great importance. Patients usually have 5-6 bowel movements per day, and continence is satisfactory in more than 90% of patients. A good pouch function strongly correlates with high quality of life. Postoperative septic complications are the main risk factor for bad pouch function and pouch failure; therefore nowadays most procedures are performed with a covering ileostomy. Quality of life is usually impaired by active ulcerative colitis, and restorative proctocolectomy improves the quality of life up to the level of a healthy reference population. Taken together, restorative proctocolectomy provides excellent results concerning function and quality of life.

Quality of life of children and adolescents with congenital anorectal malformations

anorectal malformations an at first glance invisible disorder - triggers the affected children and young people and their parents strong unease and is therefore often concealed and secretive. The problems are not less if the affected children grown up. Incontinence can affect quality of life and massive psychosocial developmental disorders can arrive (Jenetzky & Black 2008). Affected children and adolescents must make diets, they suffer from abdominal pain, incontinence and constipation, feel impaired in their body image and often they have feelings of fear and shame. In the social sphere, the children have to get difficulties to get in contact with their classmates and they are in school often absent or distracted (Grano et al. 2013). Objective: The aim of the present literature review is to describe the quality of life of children and adolescents with anorectal malformations and show developmental change in physical, psychological and social area. Method: To answer the question, a literature search was conducted. For this the relevant databases PubMed". " CINAHL with full text", ,,PsycInfo" and ,,Cochrane" were used. Results: The literature research shows, that children and young people with anorectal malformations have a worse quality of life than their healthy peers. They are ashamed, feel different than others and are afraid that they smell badly, They see themselves as unattractive and are often dissatisfied with their bodies. Among the adolescents there are significant gender differences: female adolescents, whether health or with anorectal malformations, have a worse quality of life than male adolescents (Michel et al 2009, cited by Grano et al 2013). Obviously pubertal development specificities of the two genders are responsible for this result (Patton et al. 2007, Petersen et al. 1991, cited in Grano et al. 2013). Children with fecal incontinence are in their behavior more prominent than their healthy peers and have more psychological/ psychosocial problems as their classmates in the exercise of activities of daily living, for example during routine school activities, during sports or if they say with friends (Hamid et al. 2007, cited by Grano et al. 2012). Conclusion: The multiple problems in the social, physical and psychological area make it necessary for children and adolescents with anorectal malformations to get early support (bowel management program, psychologist, group therapy). For example, affected children may begin already with 3¹/₂ years with a bowel management program to prevent negative consequences and/or to avoid social exclusion (Bischoff et al. 2009. cited in Grano et al. 2012). For parents, it is important that they learn to accept the child's illness and to help the children to cope their illness better. With this support in childhood it will be possible to accept the disease better and to integrate it into their self-image (Schmidt et al. 2010).

Fecal incontinence - Challenges and solutions

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

Barriers to seeking care for accidental bowel leakage: a qualitative study

INTRODUCTION AND HYPOTHESIS

Fewer than 50 % of women with urinary incontinence (UI) and 30 % of women with accidental bowel leakage (ABL) seek care. We sought to describe barriers to care seeking for ABL to inform development of an instrument to measure these barriers.

METHODS

We recruited women with ABL with varied prior care-seeking experiences to participate in focus groups and cognitive interviews so we could understand factors that may have prevented or delayed care seeking. Focus groups continued until thematic saturation was reached using conventional content analysis. Final themes were established and characterized by comparing within and across the focus groups and with previously described UI and ABL care-seeking barriers. Cognitive interviews were confirmatory.

RESULTS

Thirty-nine women (aged 46-85) participated in six focus groups and ten cognitive interviews; 89 % were white, 8 % African American, and 3 % Latina. We identified 12 barriers to seeking care for ABL: (1) Lack of knowledge about the condition; (2) Lack of knowledge about treatment; (3) Fear of testing/treatment; (4) Normative thinking; (5) Avoidance/denial; (6) Life impact; (7) Embarrassment/shame; (8) Self-blame; (9) Stigma; (10) Isolation; (11) Provider barriers; (12) Access limitations. These 12 barriers encompassed three overarching themes: the internalized self in relation to ABL; perceptions about ABL and its treatments; and interaction with the healthcare system.

CONCLUSIONS

ABL care-seeking barriers are similar to those described for UI, with the notable addition of lack of knowledge that ABL is a medical condition experienced by others. Interventions to promote access to effective treatments for ABL should include information about prevalence and treatability.

Esophageal and anorectal involvement in systemic sclerosis: a systematic assessment with high resolution manometry

OBJECTIVES

In systemic sclerosis (SSc), esophageal and anorectal involvements are frequent and often associated with each other. In clinical practice, esophageal explorations are often prescribed, while anorectal explorations are rarely proposed and therefore, under-recognised. However, it is well documented in the literature that early detection of anorectal dysfunction could delay and/or prevent the onset of symptoms such as fecal incontinence (FI). The main objective was the systematic evaluation and detection of esophageal and anorectal involvements in SSc patients.

METHODS

In this monocentric retrospective study, all patients with SSc addressed in the Department of Functional Digestive Explorations, North Hospital, Marseille for esophageal and anorectal explorations were included. Self-Questionnaires, evaluating the symptoms and quality of life, were filled by patients during their visit. Explorations were performed on the same day: high resolution esophageal manometry (EHRM), 3 Dimensional high resolution anorectal manometry (3DHRARM) and endo anal sonography (EUS).

RESULTS

44 patients (41 women), mean age 59.8±12 years, were included. With regard to the symptoms, 45.5% of patients had gastro-esophageal reflux disease (GERD), 66.9% dysphagia, 65.9% constipation and 77.3% FI. The incidence of esophageal dismotility was 65.9%, anorectal and both upper and lower dysfunction were 43.2%. More than 89% patients with abnormal explorations (EHRM, 3DHRARM or both) were symptomatic. Duration of SSc and altered quality of life was correlated with the severity of digestive involvement.

CONCLUSIONS

Anorectal dysfunction appears to be closely linked to esophageal involvement in SSc. Their routine screening is undoubtedly essential to limit the occurrence of severe symptoms such as FI.

Eliciting Help-Seeking Behaviors in Patients With Fecal Incontinence: Supporting Timely Access to Treatment

People with fecal incontinence (FI) symptoms often do not report their symptoms to their care providers, which may adversely impact their quality of life. Although the differential diagnosis for the cause of an individual's FI symptoms can be done by a family doctor, nurse practitioner, or a specialist, many other healthcare professionals have the training and education to competently screen patients for FI risk factors. Those individuals identified with FI symptoms can be supported to disclose this information to their healthcare professional in a timely manner. Healthcare professionals have a responsibility to encourage patients to seek medical treatment in order to ensure an accurate diagnosis for their FI symptoms, and to support clients through the process of managing symptoms including adhering to care plans to mitigate modifiable causes of FI. When clients actively seek medical help, it is referred to as help-seeking behavior. Given the sensitive nature of FI, with the associated stigma and taboo surrounding the topic, healthcare providers must conscientiously work to support each client with sensitivity and self-awareness.

An evaluation of fecal incontinence in women with urinary incontinence

OBJECTIVE

To investigate the occurrence of and risk factors for fecal and/or gas incontinence in female patients having urinary incontinence.

PATIENTS AND METHODS

741 consecutive adult female patients presenting with urinary incontinence alone (group 1, n = 700) or urinary incontinence with fecal and/or gas incontinence (group 2, n = 41) were enrolled into the study. As potential risk factors for fecal and/or gas incontinence in this population, the following variables were investigated: age, body mass index, type of urinary incontinence, childbirth history, menopausal symptoms, history of pelvic surgery, neurological disease, diabetes mellitus, tobacco use, constipation, cystocele, rectocele. Quality of life was assessed with the Urogenital Distress Inventory-Short Form (UDI-6) and the Incontinence Impact Questionnaire (IIQ-7).

RESULTS

Of the women having urinary incontinence, 5.5% also had fecal and/or gas incontinence. Associated risk factors were history of difficult delivery, postmenopausal symptoms, history of pelvic surgery and constipation. Fecal and/or gas incontinence was also associated with a lower quality of life in terms of both questionnaires.

CONCLUSIONS

Women have urinary incontinence may have also fecal and/ or gas incontinence. Particularly if they have chronic constipation, postmenopausal symptoms or history of difficult delivery or pelvic surgery they must be evaluated for this additional symptom. So we can treat these patients appropriately and increase their quality of life.

German translation and validation of the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire-IUGA revised (PISQ-IR)

INTRODUCTION AND HYPOTHESIS

Condition-specific sexual questionnaires are essential for clinical trials and important patient-reported outcome measures. The aim of the study was to translate the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire-International Urogynecology Association Revised (PISQ-IR) into German and to clinically validate it in a German-speaking population.

METHODS

The translated PISQ-IR was linguistically validated in two rounds of cognitive interviews. The final instrument was psychometrically validated in women presenting to urogynecological clinics with pelvic floor dysfunction. For analysis of criterion validity, three related self-reported measures were administered: the Female Sexual Function Index (FSFI), the Kings Health Questionnaire (KHQ), and the 36-Item Short Form Health Survey (SF-36). For external validity, PISQ-IR subscales were compared to the clinical-measures Pelvic Organ Prolapse Quantification system (POP-Q) stage, pelvic floor muscle tone, and Oxford Grading Scale. Descriptive statistics, floor and ceiling effects, internal consistency using Cronbach's alpha coefficient, and Pearson correlations were calculated for all PISQ-IR subscales.

RESULTS

The PISQ-IR was completed by 197 women, out of whom 66 (33.5 %) considered themselves not sexually active (NSA) and 131 (66.5 %) as sexually active (SA). Participants' mean age was 57 ± 12 years; 50 % were diagnosed with symptomatic POP, 74 % with urinary incontinence (UI) and 4 % with anal incontinence (AI). The PISQ-IR subscales were analyzed separately for SA and NSA women with Cronbach's alpha coefficients ranging from 0.64 to 0.94. Moderate to high correlations were observed between PISQ-IR subscales and related quality of life (QoL) scales and corresponding FSFI scales.

CONCLUSION

Initial testing of the German PISQ-IR suggests it is an internally consistent and valid tool for use in clinical practice and research.

Time to break the continence taboo

Millions of people in the UK experience continence problems that can have a devastating effect on quality of life. Nurse experts welcome new care guidance from NHS England but say that healthcare staff need to do more to raise patient awareness of available treatment options.

The impact of incontinence management on informal caregivers' quality of life

BACKGROUND

The presence of incontinence symptoms might affect the quality of life (QoL) of those providing informal care to people suffering from them, causing social isolation, financial problems, psychological and physical exhaustion.

AIMS

This study aimed at assessing whether urinary and/or fecal incontinence in people aged 60 and over affects the level of burden in their informal caregivers.

METHODS

QoL was assessed amongst 304 informal caregivers of older people suffering from urinary and/or fecal incontinence, and compared to that reported by 305 caregivers of non-incontinent older relatives, all living in Italy. All participants were administered a questionnaire focused on: characteristics and conditions of the cared for; details of the care activity; emotions experienced by caregivers; attitudes of caregivers; reasons for providing care; availability of information and support; demographics.

RESULTS

Findings show that, when no incontinence was reported, the longer was the caregiving situation, the better was the caregivers' QoL, which was instead negatively affected by the lack of a support network. As for caregivers' feelings, neither positive nor negative emotions influenced their QoL in a significant way. In terms of caregiver's role, those who felt overwhelmed or loaded with responsibility reported a lower QoL, while the opposite was found among those who felt rewarded and supported, even when incontinence-of any kind-was present.

CONCLUSIONS

The management of incontinence does have a negative impact on caregivers' QoL, but subjective factors might play a mitigating role on such an impact.

Quality of Life Aspects Determining The-Bio-Psycho-Social Functioning of Patients in The-Perspective of a Planned Extensive Sphincter's Repair Procedure

Damage to the sphincter, regardless of its pathogenesis, consists in the impossibility to control the physiology, or the so-called faecal incontinence. This implies changes in the whole bio-psycho-social functioning of the patients, and thus affects the satisfaction with their quality of life, conditioned by their health status. The problem affects around 5 to 7% of the population. Often enough, the only hope for those patients are repair procedures of the sphincter mechanism. The aim of the study was to evaluate key aspects of quality of life which determine the psycho-social status of patients with endogenous or iatrogenic sphincter damage in the perspective of a planned extensive sphincter's repair procedure.

MATERIAL AND METHODS

The study group consisted of 52 people, 26 women and 26 men, aged 19-72. The scale by Rockwood--Fecal Incontinency Quality of Life--was used as the basic research tool which evaluates the quality of life in four aspects: 1/behavioral (Lifestyle) 2/cognitive (Coping) 3/emotional (Depression) 4/overall self-assessment (Embarrasment). The degree of incontinence was determined based on point scales of Jorge Wexner (JW scale) and the Fecal Incontinenece Severity Index (FISI scale). Structured diagnostic interview was also used in the study.

RESULTS

The results show that lack of control over the basic physiological functions disintegrates the quality of life in all evaluated aspects related to somatic, psychological and social functioning. FIQL: Lifestyle (LS) - 1.96 pts Coping (C) - 1.67 pts Depression (D) - 2.1 pts Embarrasment (E) - 1.79 pts Conclusions. The FIQL results presented explain the fact that among 52 patients followed, 50 decided to conduct extensive reconstructive procedures, although the results are not statistically optimistic and the risk of complications is relatively high.

Validity and reliability of a Lithuanian version of low anterior resection syndrome score

BACKGROUND

Up to 90 % of patients undergoing low anterior resection complain of increased daily bowel movements, urgency, and a variable degree of incontinence. A symptom-based scoring system for bowel dysfunction after low anterior resection for rectal cancer has recently been developed and validated. The aim of our study was to adapt the low anterior resection syndrome (LARS) scale questionnaire to the Lithuanian language, and assess its psychometric properties.

METHODS

The LARS questionnaire was translated into Lithuanian by the Scientific Advisory Committee of the Medical Outcomes Trust using a standard procedure of double-back translation. The Lithuanian version of the LARS (LARS-LT) questionnaire was completed by 111 patients who underwent low anterior resection with total mesorectal excision in the period from January 1, 2008, to December 31, 2012, at the National Cancer Institute. An anchor question from the Wexner score assessing the impact of bowel function on lifestyle was included. A subgroup of 20 patients completed the LARS-LT questionnaire twice. Validity was tested using a factor analysis, and internal reliability was estimated using the Cronbach's alpha and intraclass correlation coefficients.

RESULTS

Twenty-seven patients (25 %) had no LARS, 26 (24 %) had minor LARS, and 55 (56 %) had major LARS. The response rate was 60.7 %. The LARS-LT showed significantly high reliability and internal consistency [Cronbach's α = 0.88, interclass correlation coefficient-0.86 (0.71-0.98)]. The LARS score showed significant correlations with the lifestyle question (p < 0.05). It could not detect differences between female and male patient groups (p = 0.33), patients' age (p = 0.45), patients who had/had not undergone radiation therapy (p = 0.07), and those in whom the distal edge of the tumor was close to or far from the anal verge (p = 0.17).

CONCLUSIONS

The Lithuanian version of the LARS-LT shows acceptable psychometric properties and can be considered a valuable and specific instrument to assess bowel function in rectal cancer patients, both for research purposes and in clinical practice.

Reducing and managing faecal incontinence in people with advanced dementia who are resident in care homes: protocol for a realist synthesis

INTRODUCTION

Faecal incontinence (FI) is the involuntary loss of liquid or solid stool that is a social or hygienic problem. The prevalence of FI in residents of care homes is high, but it is not an inevitable consequence of old age or dementia. There is good evidence on risk factors, but few studies provide evidence about effective interventions. There is a need to understand how, why, and in what circumstances particular programmes to reduce and manage FI are effective (or not) for people with dementia. The purpose of this review is to identify which (elements of the) interventions could potentially be effective, and examine the barriers and facilitators to the acceptability, uptake and implementation of interventions designed to address FI in people with dementia who are resident in care homes.

METHODS AND ANALYSIS

A realist synthesis approach to review the evidence will be used which will include studies on continence, person-centred care, implementation research in care homes, workforce and research on care home culture. An iterative four-stage approach is planned. Phase 1: development of an initial programme theory or theories that will be 'tested' through a first scoping of the literature and consultation with five stakeholder groups (care home providers, user representatives, academics and practice educators, clinicians with a special interest in FI and continence specialists). Phase 2: a systematic search and analysis of published and unpublished evidence to test and develop the programme theories identified in phase 1. Phase 3: validation of programme theory/ies with a purposive sample of participants from phase 1.

ETHICS AND DISSEMINATION

The overall protocol does not require ethical review. The University research ethics committee will review interviews conducted as part of phase 1 and 3. The final fourth phase will synthesise and develop recommendations for practice and develop testable hypotheses for further research.

A Qualitative Study of Family Caregiver Experiences of Managing Incontinence in Stroke Survivors

Background

Incontinence is a common problem faced by family caregivers that is recognized as a major burden and predictor of institutionalization. However, few studies have evaluated the experiences of family caregivers caring for stroke survivors with incontinence.

Purpose

To describe experiences of caregivers managing incontinence in stroke survivors.

Design

This qualitative descriptive study employed a grounded-theory approach.

Methods

Semi-structured in-depth interviews with ten family caregivers of stroke survivors with incontinence were conducted during 2011. Audiotaped interviews were transcribed and analyzed using content analysis.

Findings

Data analysis identified four themes: chaos, hypervigilance, exhaustion, and creating a new life. There were nine related subcategories: fluster, dirtiness, urgency, fear of potential health-hazard, physically demanding and time-consuming, mentally draining, financial burden, learning by doing, and attitude adjustment. Together, these described a process of struggling to cope with the care of stroke survivors with urinary/fecal incontinence. Of the four categories, “creating a new life” developed gradually over time to orient caregivers to their new life, while the other three categories occurred in a chronological order.

Conclusion

The research highlighted unique caring experiences of family caregivers of stroke patients, which focused solely on the ‘incontinence issue’. Understanding these experiences may help nurses provide better support and resources for family caregivers when caring for stroke survivors with incontinence.

Absenteeism, educational plans, and anxiety among children with incontinence and their parents

BACKGROUND

Children with incontinence have more absenteeism, poorer academic performance, and potential social difficulties during the school years. These children and their parents are at risk for illness-related anxiety. Whereas educational plans are designed to remediate educational, medical, and social-emotional barriers at school, little research has explored the relationship among absenteeism, educational plans, and anxiety for this population.

METHODS

Eighty-three families provided demographic information and completed either the Revised Children's Manifest Anxiety Scale Second Edition (RCMAS-2) or the Adult Manifest Anxiety Scale (AMAS-A). A multiple regression analysis was conducted to determine the relationships among these variables.

RESULTS

Children with chronic illness resulting in incontinence had greater than expected rates of absenteeism. A high level of absenteeism was a significant predictor of parental anxiety, but not child anxiety. Over one third reported having no plan in place to support the child's needs at school. However, when a plan was present, it had no impact on child or parental anxiety.

CONCLUSIONS

Absenteeism contributes to familial anxiety and educational difficulties. Despite the potential for educational plans to support these children at school, these plans are underutilized for children with incontinence. This population requires more attention to their academic and social-emotional well-being at school.

The nature and impact of incontinence in men who have undergone prostate surgery and implications for nursing practice

AIM

The aim of this study was to increase knowledge and understanding of the nature and experiences of incontinence in men one or more years post prostate surgery.

METHODS

This descriptive study used a sample of convenience. Two hundred and twelve male participants who had undergone prostate surgery more than a year ago were asked about their experiences of incontinence. Participants were asked to fill in two questionnaires: The Expanded Prostate Cancer Index Composite and the Incontinence Impact Questionnaire. Participants were also asked about their prostate surgery, their health seeking behaviour in relation to incontinence, the type of discharge information they were given, and demographic information.

RESULTS

Sixty-six percent of participants indicated that, in the last four weeks, their overall urinary function had been a problem and 36.3% reported their bowel habits were problematic, which affected the quality of their lives. In addition, 41% of participants reported that they were not given discharge information regarding the possibility of developing urinary incontinence and sexual problems post prostate surgery.

CONCLUSIONS

Health care professionals should pay more attention to routinely providing information to all men regarding the possibility of developing incontinence or sexual problems post prostate surgery. This may assist them to better manage these problems.

Nintendo related injuries and other problems: review

OBJECTIVE

To identify all reported cases of injury and other problems caused by using a Nintendo video gaming system.

DESIGN

Review.

DATA SOURCES AND REVIEW METHODS

Search of PubMed and Embase in June 2014 for reports on injuries and other problems caused by using a Nintendo gaming system.

RESULTS

Most of the 38 articles identified were case reports or case series. Injuries and problems ranged from neurological and psychological to surgical. Traditional controllers with buttons were associated with tendinitis of the extensor of the thumb. The joystick on the Nintendo 64 controller was linked to palmar ulceration. The motion sensitive Wii remote was associated with musculoskeletal problems and various traumas.

CONCLUSIONS

Most problems are mild and prevalence is low. The described injuries were related to the way the games are controlled, which varies according to the video game console.

Developing biographies: the experiences of children, young people and their parents of living with a long-term condition

This article reports on data from a qualitative interview study that sought to understand the experiences, choices and actions of children and young people undergoing surgery for a long-term condition and that of their parents. Using the concept of biography the article examines how the biographies of children, young people and their parents can be influenced by surgery and the ongoing management of a long-term continence condition. This article challenges previous work that characterises the presence of a condition from birth as a continuous and normal part of the illness experiences of these patients. Although this may be the case in some instances, children, young people and their parents can experience diverse and changing experiences associated with ongoing condition management as well as surgery. Biographical continuity, enrichment and disruption are all relevant concepts for such patients living with a long-term continence condition. These can be influenced by their previous experiences of their condition, their expectations, and dynamics with parents, including changes associated with development and the increasing independence of young people.

Use of a visual analog scale for evaluation of bother from pelvic organ prolapse

OBJECTIVES

A specified anatomical degree of prolapse may cause no bother in one individual and a severe form of bother in another. The aim of this study was to determine the factors contributing to the degree of bother due to a given degree of prolapse, to help with the clinical evaluation of patients and planning of preventive intervention trials and surgical treatment.

METHODS

Consecutive patient records of 654 women who had attended a urogynecology unit between August 2011 and December 2012 were reviewed. All patients underwent a standardized interview, clinical examination and four-dimensional translabial ultrasound scan. The degree of bother was evaluated using a visual analog scale.

RESULTS

Six hundred and thirty-six women were included in the analysis, with ultrasound data available for cystocele, rectocele and enterocele descent and rectocele depth measurements and 442 for uterine descent. 313 women (49.2%) had subjective symptoms of female pelvic organ prolapse at a mean bother score of 6.0 ± 2.6. Average bother score for the complete dataset was 3.0 ± 3.5. Parity, vaginal delivery, levator avulsion, any significant clinical prolapse or prolapse seen on ultrasound were associated with prolapse bother and all clinical and ultrasound measures of pelvic organ descent remained significant or near significant on multivariate analysis.

CONCLUSIONS

Quantification of prolapse bother using a visual analog scale is valid and repeatable and may represent a simple tool for use in clinical practice.

Factors associated with toileting disability in older adults without dementia living in residential care facilities

BACKGROUND

Older adults without dementia living in residential care facilities with toileting disability have increased care costs and dependency. Understanding associated factors could guide prevention and management strategies.

OBJECTIVE

The aim of this study was to identify the prevalence of and factors associated with toileting disability in this population.

METHODS

This was a cross-sectional analysis of the 2010 National Survey of Residential Care Facilities. A subsample (n = 2,395) of adults aged 65 years or older, without dementia, and with the potential to implement behavioral interventions was examined. Associated factors were classified according to the disablement process as pathologies, impairments, functional limitations, coexisting disabilities, and intraindividual and extraindividual factors. Logistic regression models accounting for the stratified two-stage probability sampling design were used to identify factors associated with toileting disability.

RESULTS

Residents were mostly White women, aged 85 years and older. Prevalence of toileting disability was 15%. Associated factors included reporting fair or poor health; living in a facility with four or less residents; living in a for-profit facility; having bowel incontinence, urinary incontinence, more physical impairments, and visual and hearing impairments; and needing assistance with bathing, dressing, and transferring.

DISCUSSION

Multicomponent and multidisciplinary prevention and management efforts should be designed for residents without dementia. Future studies testing the efficacy of prevention efforts are needed and should include treatments for incontinence; physical activity programs targeting impairments with walking, standing, sitting, stooping, reaching, and grasping; and therapy to improve dressing, bathing, and transferring skills.

Patients' experience compared with physicians' recommendations for treating fecal incontinence: a qualitative approach

INTRODUCTION AND HYPOTHESIS

Using qualitative methods, we compared physician-recommended treatment options for fecal incontinence to patient knowledge of treatment options. Our hypothesis was that physician recommendations were not being communicated well to patients and that this impaired patients' ability to cope with fecal incontinence.

METHODS

Cognitive interviews were conducted with physicians who routinely care for women with fecal incontinence. Physicians were asked to describe their typical nonsurgical treatment recommendations and counseling for fecal incontinence. Women with bothersome fecal incontinence were recruited to participate in focus groups and asked about personal experience with fecal incontinence symptoms and treatment options. For both physician interviews and patient focus groups, qualitative data analysis was performed using grounded-theory methodology.

RESULTS

Physicians identified several barriers patients face when seeking treatment: lack of physician interest toward fecal incontinence, and patient embarrassment in discussing fecal incontinence. Physicians universally recommended fiber and pelvic floor exercise; they felt the majority (approximately 70-80 %) of patients will improve with these therapies. Collectively, patients were able to identify all treatment recommendations given by physicians, although many had discovered these treatments through personal experience. Three concepts emerged regarding treatment options that physicians did not identify but that patients felt were important in their treatment: hope for improvement, personal effort to control symptoms, and encouragement to go on living life fully.

CONCLUSIONS

Whereas physicians had treatment to offer women with fecal incontinence, women had already found the best treatments through personal research and effort. Women want to hear a message of hope and encouragement and perceive personal effort from providers.

[Multivariate analysis of risk factors of the anal functional disorders after abdominal-anal resection with delayed formation of colonic-anal anastomosis]

Multivariate analysis of clinical factors was conducted on the material histories of 195 patients treated between 2004 and 2006. In Donetsk regional antitumor center, which for rectal cancer (RC) is made abdomino-anal resection of the rectum with the delayed formation koloanal anastomosis after bringing down the colon to the perineum. In 97 patients the operation was performed with the use of electric welding soft tissue (EWST), in 98--a standard way. Studied the quality of life of patients using a questionnaire QLQ C30-CR38 and the function of the anal incontinence (Wexner scale). It is established, that the greatest influence on the function of the anal continence have a view of a combined and complex treatment, radicality intervention, the method of forming koloanal of anastomosis. Application EWST the second stage of surgery to cut off excess relegated intestine helped reduce the risk of poor function of the anal continence.

Neuromodulation for fecal incontinence: An effective surgical intervention

Fecal incontinence is a disabling symptom with medical and social implications, including fear, embarrassment, isolation and even depression. Most patients live in seclusion and have to plan their life around the symptom, with secondary impairment of their quality of life. Conservative management and biofeedback therapy are reported to benefit a good percentage of those affected. However, surgery must be considered in the non-responder population. Recently, sacral nerve electrostimulation, lately named neuromodulation, has been reported to benefit patients with fecal incontinence in randomized controlled trials more than placebo stimulation and conservative management, by some unknown mechanism. Neuromodulation is a minimally invasive procedure with a low rate of adverse events and apparently favorable cost-efficacy profile. This review is intended to expand knowledge about this effective intervention among the non-surgically skilled community who deals with this disabled group of patients.

Fecal incontinence: help for patients who suffer silently

Once you've identified patients with this embarrassing condition, achieving optimal outcomes hinges on your familiarity with advances like sacral nerve stimulation.

Factors associated with quality of life among women with fecal incontinence

INTRODUCTION AND HYPOTHESIS

Fecal incontinence (FI) is a distressing, highly prevalent condition affecting quality of life (QOL). The aim of our study was to identify predictors of moderate/severe health-related QOL among women with FI.

METHODS

Data were collected from women presenting to a multispecialty clinic from January 2005 to July 2009 with FI. All completed questionnaires on demographics and validated instruments including the Fecal Incontinence Quality of Life Instrument (FIQL), Patient Health Questionnaire (PHQ) for depression, and Fecal Incontinence Severity Index (FISI). Logistic regression was used to identify factors associated with moderate/severe FI.

RESULTS

The study included 226 women with an average age of 59.2 years (SD = 14.1); 92 % were Caucasian, 67 % were married, and the average body mass index was 30.0 (SD = 8.6). Their QOL was moderately/severely affected by FI in 35.6 %. Mean overall FIQL score was 2.5 (SD = 0.8). Median QOL subscale measures were: lifestyle = 2.7 (SD = 1.0), coping = 2.09 (SD = 0.9), depression = 2.8 (SD = 1.0), and embarrassment = 2.2 (SD = 0.9). Average FISI score was 31.6 (SD = 15.7) and average depression score on the PHQ was 8.93 (SD = 8.1). In univariate analyses, diabetes, irritable bowel symptoms, prior hysterectomy, history of previous medical care for FI, higher FISI and PHQ scores were associated with moderate/severe FIQL scores (p < 0.05). Higher PHQ scores and prior hysterectomy significantly predicted moderate/severe QOL in logistic regression analysis (p < 0.05).

CONCLUSIONS

We confirm that women with higher depression scores and prior hysterectomy have moderate/severe QOL impairment. When evaluating FI, screening for depression should be undertaken.

Living with faecal incontinence: follow-up to a research project

This paper reports on a descriptive qualitative five-year follow-up to an initial UK-based grounded theory study entitled 'Living with Faecal Incontinence.' Both studies collected data using in-depth guided interviews. The aim of the follow-up study was to identify any changes including adaptation and establish determining factors for people with faecal incontinence. Of the 22 participants in the original study, 11 joined the follow-up. Of these, nine participants demonstrated degrees of adaptation, assisted by symptom improvement using practical means or accepted what cannot be changed, downgrading their aspirations. One, having progressed, had become static in an intermediate position, while another displayed little adaptation. Health professionals can assist adaptation by being aware of clinical interventions to improve symptoms and practical means available. Where appropriate, the use of role models may help. Role model effectiveness, together with further long-term investigation into living with faecal incontinence, provide topics for future research.

The association between urinary and fecal incontinence and social isolation in older women

OBJECTIVE

To describe the association between social isolation and urinary incontinence and fecal incontinence in older women.

METHODS

We conducted a secondary database analysis of the National Social Life, Health and Aging Project for women aged 57 to 85 years old. Our primary outcome was self-report of often feeling isolated. We explored self-report of daily urinary incontinence and weekly fecal incontinence. Two logistic regression analyses were performed to assess the association between often feeling isolated and (1) daily urinary incontinence and (2) weekly fecal incontinence.

RESULTS

A total of 1412 women were included in our analysis. Daily urinary incontinence was reported by 12.5% (177/1412) of community-dwelling older women. More women with daily urinary incontinence reported often feeling isolated (6.6%; 95% confidence interval [CI], 1.3-11.9 vs 2.6%; 95% CI, 1.7-3.5; P = .04) compared with women without daily urinary incontinence. Women with daily urinary incontinence had 3.0 (95% CI, 1.1-7.6) increased odds of often feeling isolated after adjusting for depressive symptoms, age, race, education, and overall health. Weekly fecal incontinence was reported by 2.9% (41/1412) of women. Weekly fecal incontinence and often feeling isolated were associated on univariable analysis (crude odds ratio, 4.6; 95% CI, 1.4-15.1). However, after adjusting for depressive symptoms, age, race, education, and overall health the association between weekly fecal incontinence and often feeling isolated was not significant (adjusted odds ratio, 0.65; 95% CI, 0.1-5.3; P = .65).

CONCLUSION

After adjusting for confounders, daily urinary incontinence was significantly associated with often feeling isolated. Weekly fecal incontinence was not found to be associated with often feeling isolated on multivariable logistic regression.

Understanding the health and social care needs of people living with IBD: a meta-synthesis of the evidence

AIM

To undertake a metasynthesis of qualitative studies to understand the health and social needs of people living with inflammatory bowel disease (IBD).

METHODS

A systematic search strategy identified qualitative studies exploring the phenomenon of living with inflammatory bowel disease. Databases included MEDLINE, PsychInfo, EMBASE, CINAHL and the British Nursing Index via the OVID platform. Qualitative search filters were adapted from Hedges database (http://www.urmc.rochester.edu/hslt/miner/digital_library/tip_sheets/Cinahl_eb_filters.pdf). Qualitative empirical studies exploring the health and social needs of people living with inflammatory bowel disease were selected. Study eligibility and data extraction were independently completed using the Critical Appraisal Skills Programme for qualitative studies. The studies were analysed and synthesised using metasynthesis methodology. The themes from the studies allowed for common translations into a new interpretation of the impact of living with inflammatory bowel disease.

RESULTS

Of 1395 studies, six published studies and one unpublished thesis fulfilled the inclusion criteria. First iteration of synthesis identified 16 themes, 2nd iteration synthesised these into three main 2nd order constructs: "detained by the disease"; "living in a world of disease" and "wrestling with life". "Detained by the disease" is the fear of incontinence, the behaviour the patients display due to the fear, and the impact this has on the individual, such as social isolation and missing out on life events. All of these serve to "pull" the patient back from normal living. "Living in a world of disease" is the long term effects of living with a long term condition and the fear of these effects. "Wrestling with life" is the continued fight to thrive, the "push" to continue normal living.

CONCLUSION

The metasynthesis provides a comprehensive representation of living with IBD. The unmistakeable burden of incontinence is exposed and its ongoing effects are demonstrated. The combined overall impact of living with IBD is the tension these patients live with: "Pushed and pulled: a compromised life", people living with IBD experience a constant conflict throughout their lives, they push to be normal but IBD pulls them back. The impact of the fear of incontinence and behaviour of the individual as a result, requires further qualitative enquiry.

Obstetrical anal sphincter laceration and anal incontinence 5-10 years after childbirth

OBJECTIVE

The purpose of this study was to investigate the long-term impact of anal sphincter laceration on anal incontinence.

STUDY DESIGN

Five to 10 years after first delivery, anal incontinence and other bowel symptoms were measured with the Epidemiology of Prolapse and Incontinence Questionnaire and the short form of the Colorectal-Anal Impact Questionnaire. Obstetric exposures were assessed with review of hospital records. Symptoms and quality-of-life impact were compared among 90 women with at least 1 anal sphincter laceration, 320 women who delivered vaginally without sphincter laceration, and 527 women who delivered by cesarean delivery.

RESULTS

Women who sustained an anal sphincter laceration were most likely to report anal incontinence (odds ratio, 2.32; 95% confidence interval, 1.27-4.26) and reported the greatest negative impact on quality of life. Anal incontinence and quality-of-life scores were similar between women who delivered by cesarean section and those who delivered vaginally without sphincter laceration.

CONCLUSION

Anal sphincter laceration is associated with anal incontinence 5-10 years after delivery.

Quality of life impact in women with accidental bowel leakage

BACKGROUND

Accidental bowel leakage (ABL) is associated with negative impact on quality of life (QoL) and many women do not seek care.

OBJECTIVES

To assess current perspectives and QoL among women with ABL; to identify factors associated with severe impact on condition-specific QoL; and to describe care-seeking for ABL.

DESIGN, SETTING AND PARTICIPANTS

Sub-analysis of 1096 women with ABL identified through an internet-based, self-administered survey of 5817 US women ≥ 45 years old.

MAIN OUTCOME MEASURE

Severe impact on QoL was defined as response of 'affects very much' or 'greatly' to any of seven domains within Pelvic Floor Impact Questionnaire.

RESULTS

QoL data were available for 85.6% (938/1096) of women with ABL. Domains relating to frustration, emotional health and participation in social activities demonstrated the greatest negative impact, with 39.2% (95% CI 36.1-42.4%) having overall severe impact. More frequent ABL, faecal urgency, nocturnal bowel movements, FI without warning, stress FI, weekly urinary incontinence and underlying bowel disorder were associated with severe impact on QoL. Of the 28.6% (268/938) of women who spoke to a physician about their ABL, the majority did so with a general practitioner or family physician (56.0%, 150/268). Only 19.0% (51/268) consulted an internist or gastroenterologist [27.2% (73/268)].

CONCLUSIONS

Nearly 40% of adult women with ABL have severe negative impact on QoL, but less than one-third seek care. More than half of those who seek care do so with their primary care provider. Improved awareness of the prevalence and impact of FI by these providers may decrease barriers and improve QoL.

Accidental bowel leakage in the mature women's health study: prevalence and predictors

BACKGROUND

The 2007 National Institutes of Health incontinence consensus panel emphasised the need for classification and identification of persons at risk for faecal incontinence (FI).

OBJECTIVES

To explore the prevalence of FI; to characterise severity and 'bother'; and to identify factors associated with FI in a large sample of community-dwelling women.

DESIGN, SETTING, AND PARTICIPANTS

A cohort of US women ≥ 45 years old was surveyed via an internet-based questionnaire between September 2009 and April 2010.

MAIN OUTCOME MEASURE

Accidental leakage of liquid or solid stool at least once in the last 12 months.

KEY RESULTS

Eighty-five per cent of those surveyed (5817/6873) participated and were predominantly white, well educated and insured. The prevalence of FI at least once in the past year was 18.8% (1096/5817; 95% CI: 17.8-19.9%) and 97% of these women were bothered by this frequency of leakage. Among 938 respondents with FI, 71.1% (667) preferred the term 'accidental bowel leakage' (ABL) over faecal or bowel incontinence. Bowel disorders, urinary incontinence, stroke, age 55-64, diabetes mellitus and prior vaginal delivery were associated with an increased odds of FI, whereas being married, Black or American Indian/Alaska Native race/ethnicity, and income ≥ $40,000 per year were associated with a decreased odds of FI.

CONCLUSIONS

Nearly one-fifth of mature US women suffer from bothersome leakage of stool at least yearly and the overwhelming majority prefer the term 'Accidental Bowel Leakage.' Those with bowel disorders and urinary incontinence are most likely to experience ABL. Incorporating questions regarding ABL or bowel and bladder disorders into routine screening may aid in identifying silent sufferers of ABL.

Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children

BACKGROUND

Faecal incontinence is a common and potentially distressing disorder of childhood.

OBJECTIVES

To assess the effects of behavioural and/or cognitive interventions for the management of faecal incontinence in children.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 28 October 2011), which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and CINAHL, and handsearching of journals and conference proceedings, and the reference lists of relevant articles. We contacted authors in the field to identify any additional or unpublished studies.

SELECTION CRITERIA

Randomised and quasi-randomised trials of behavioural and/or cognitive interventions with or without other treatments for the management of faecal incontinence in children.

DATA COLLECTION AND ANALYSIS

Reviewers selected studies from the literature, assessed study quality, and extracted data. Data were combined in a meta-analysis when appropriate.

MAIN RESULTS

Twenty one randomised trials with a total of 1371 children met the inclusion criteria. Sample sizes were generally small. All studies but one investigated children with functional faecal incontinence. Interventions varied amongst trials and few outcomes were shared by trials addressing the same comparisons.Combined results of nine trials showed higher rather than lower rates of persisting symptoms of faecal incontinence up to 12 months when biofeedback was added to conventional treatment (OR 1.11 CI 95% 0.78 to 1.58). This result was consistent with that of two trials with longer follow-up (OR 1.31 CI 95% 0.80 to 2.15). In one trial the adjunct of anorectal manometry to conventional treatment did not result in higher success rates in chronically constipated children (OR 1.40 95% CI 0.72 to 2.73 at 24 months).In one small trial the adjunct of behaviour modification to laxative therapy was associated with a significant reduction in children's soiling episodes at both the three month (OR 0.14 CI 95% 0.04 to 0.51) and the 12 month assessment (OR 0.20 CI 95% 0.06 to 0.65).

AUTHORS' CONCLUSIONS

There is no evidence that biofeedback training adds any benefit to conventional treatment in the management of functional faecal incontinence in children. There was not enough evidence on which to assess the effects of biofeedback for the management of organic faecal incontinence. There is some evidence that behavioural interventions plus laxative therapy, rather than laxative therapy alone, improves continence in children with functional faecal incontinence associated with constipation.